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Enf.Por Tabaquismo Clase Teorico PráCtica
- 1. Cesación tabáquica en pacientes con enfermedades respiratorias Dra. Patricia K. Aruj HCJSM
- 2. Enfermedad humana que responde a fuerzas económicas
- 6. Exposición al humo de tabaco Tóxicos del humo del tabaco Factores de suceptibilidad Edad, enf subyacentes Fuente Tipo de Cigarrillo Dosis Geometría vía aérea Grado de inhalación Absorción Metabolismo Excreción Droga biológicamente activa Efectos adversos
- 9. Por qué debería dejar ? Enfermedades pulmonares obstructivas y cesación tabáquica
- 13. El tabaquismo mata 655,000 personas por año por diferentes causas www.death s fromsmoking.net EU25 (European Union), year 2000 * 190,000 (85%) de las 224,000 muertes por cancer de pulmón 285,000 cancer* 183,000 vascular (CV, ACV, vascular periférico) 113,000 respiratorias 74,000 otras
- 18. Por qué debería dejar ? “Ya estoy enfermo. El daño está hecho ." Enfermedades pulmonares obstructivas y cesación tabáquica
- 19. Las consecuencias de seguir fumando
- 20. Asma y tabaco N.C. Thomson et al, Eur Respir J 2004
- 22. Los beneficios de dejar de fumar
- 23. Dejar de fumar agrega años de vida Doll et al, BMJ 2004; 328: 1519-1527
- 24. Efectos de la cesación tabáquica en la declinación del FEV1 ( o: cesación tabáquica; • : sigue fumando) Anthonisen NR et al. JAMA 1994
- 29. " Conozco alguien que empeoró su asma al dejar de fumar” “Conozco alguien que comenzó a toser luego de dejar de fumar” Enfermedades pulmonares obstructivas y cesación tabáquica
- 31. Por qué debería dejar ? Ya es demasiado tarde Cancer de pulmón y cesación tabáquica
- 34. “ ¿Cuándo debería dejar?” Cancer de pulmón y cesación tabáquica
- 36. Cómo es el proceso para dejar de fumar?" Cesación tabáquica
- 37. FUMAR Placer? Problema? Dependencia
- 39. Cuán difícil es dejar? Total fumadores ~2–3% Tienen éxito en dejar ~ 70% Desean dejar ~ 30% Tratan de dejar 1 . Bridgwood et al, General Household Survey 1998. 2 . West , Getting serious about stopping smoking 1997. 3 . Arnsten , Prim Psychiatry 1996.
- 41. Fuma el paciente? Motivación para dejar Ex-tabaquista Opciones de tratamiento Promover motivación Prevenir recaídas No Intervención Si No Sí No Sí No Asentarlo en la HC El Proceso de Dejar de Fumar
- 42. Diferentes Tipos de Fumadores
- 44. Estadíos de cambio conductual Prochaska and DiClemente Precontemplacion Sin intención Contemplación Intención futura Preparación mes Acción 2 sem Mantenimiento Recaída Cambio Establecido
- 45. El proceso de dejar de fumar Raw et al, Thorax 1998. Consensus Statement JAMA 2000 A veriguar - Grado de tabaquismo A consejar “ Dejar de fumar’ A rreglar Ayudar al paciente a dejar Proveer soporte farmacológico y no farmacológico Seguimiento A A - Informarle acerca de los riesgos de continuar A sistir A A
- 47. Cuál es la probabilidad de éxito? Cesación tabáquica
- 49. Cuáles son los puntos de corte del CO exhalado?" Cesación tabáquica
- 51. En cuánto tiempo se observan beneficios? " Cesación tabáquica
- 52. Dejar de fumar Por qué? Hay algún beneficio ??? Tiempo luego De dejar 20 minutos TA, FC y circ periférica mejoran 8 horas Nicotina & CO caen 50%. PaO 2 - N 24 horas Nicotina eliminada Mejoran gusto y olfato 48 horas CO normal, clearance Mucociliar, cae riesgo de IAM 72 horas Mejor descanso y energía 2-12 sem Mejoría circulatoria 3-9 meses Menor tos y sibilancias 1 año Reducción riesgo IAM 50% 10 años Reducción Ca pulmón 50%. Riesgo de IAM vuelve al normal 15años Riesgo basal de ACV
- 54. Depedencia Cuestionario de Fagerstr ö m 1. ¿Cuanto tiempo pasa entre que se levanta y fuma el primer cigarrillo? Dentro de los 1º cinco minutos (3 pts) 6 - 30 min (2 pts) 31 - 60 min (1 p) Luego 60 min (0 p) 2. ¿Encuentra difícil no fumar en lugares prohibidos? Si ( 1 p) No (0 p) 3. ¿Cuál de todos los cigarrillos es el más difícil de evitar? El primero (1 p) Cualquier otro (0 p) 4. ¿Cuántos cigarrillos fuma por día ? 10 o menos (0 p) 11-20 (1 p) 21-30 (2 pts) 31 o más (3 pts) 5.¿Fuma más a la mañana que a la tarde ? Si (1 p) No (0 p) 6¿Fuma aún si se siente tan enfermo como para pasar el día en cama ? Sí (1 p) No (0 p) 0-2 no dep 3-6 dep 7-10 alta dep
- 57. Tabaquismo: Una enfermedad crónica Intervenciones para dejar de fumar Consejo Farmacoterapia Intervenciones conductuales La dependencia nicotínica debe tratarse
- 58. Esfuerzo personal 3% Folletos 4% Consejo médico 5% Consejo médico+TRN 6% Centros especializados 10% +TRN 20% + nuevas drogas 30-50% % abstinencia anual * Parrot et al, Thorax 1998. ** Richmond , Int J Tuberc Lung Dis 1999. Formas de dejar de fumar
- 60. Qué tipo de medicación usar?" Cesación tabáquica
- 62. Plan de cesación tabáquica sem 0 1 2 3 4 5 6 7 8 Prep. Soporte Fecha Bup TRN
- 64. Racional para la terapia de reemplazo nicotínico Fumar implica una dependencia física y psíquica Primero se reemplaza la nicotina de los cigarrillos para controlar la abstinencia mientras se reduce su consumo Luego se desciende gradualmente el reemplazo cuando el hábito ya no es un problema
- 69. Métodos aversivos Acetato plata No efecto (2 studios) Lancaster T, Stead LF. Cochrane Database Syst Reviews 2004 . Hábitos Fumar rápido, sostener el humo Provocan displacer
- 70. Hypnosis No evidencia (9 studios) Abbot NC, Stead LF, White AR, Barnes Cochrane Database Syst Reviews 1998 Hábitos Minimizar la tentación Evitar Alcohol, café, amigos fumadores, fiestas Cambiar Cambiar rutinas, diferentes marcas de café, etc
Notas del editor
- Annual deaths from smoking Smoking kills about 655,000 people a year. [CLICK] About 290,000 die in middle age from smoking [CLICK] Many of those killed in middle age … Of course, some of those killed by smoking in middle age might have died soon anyway from another cause, but some would have lived on for 10, 20, 30 or more good years. [CLICK] About 22 years of life are lost … Those who are killed while still in middle age lose, on average, about 22 years. ( Of course, this is not the same as saying that all smokers lose 22 years of life expectancy . This applies only to the smokers who are killed in middle age by the habit.)
- Smoking causes about three times as many deaths as all non-medical causes put together [CLICK] [White bar and text appear to indicate non-medical deaths] 235,461 non-medical Understandably, sudden deaths from non-medical causes - such as murder, accidents and natural disasters - capture our attention and the attention of the media, especially since some of them occur well before middle age. This 235,461 is the total number of deaths from all non-medical causes recorded for the year 2000. [CLICK] [Orange bar and text appear to indicate deaths from smoking] 655,000 smoking And this 655,000 is the number of deaths from smoking in the same period. The deaths from smoking may not be as newsworthy, but they are just as real, whether they are from lung cancer, or from the many other diseases that smoking can cause.
- Smoking kills about 655,000 people a year, from many different diseases [Pie-chart builds in sections on each click] [CLICK] 285,000 cancer and lung cancer footnote: Smoking causes many deaths from cancer. It is a cause of most of the lung cancer deaths in the world and it also causes some deaths from cancer of other parts of the body, including the mouth, throat, stomach, pancreas, liver and bladder. (This includes 85% of the lung cancer deaths. There is a relatively small number of lung cancer deaths that are not caused by smoking. Indeed, even among smokers, a few of the lung cancer deaths are not caused by smoking. Still, however, the large majority of all lung cancer deaths are caused by smoking.) [CLICK] 183,000 vascular: Smoking causes even more deaths from other diseases than from cancer. Two of the most important consequences are heart disease and stroke, but smoking can also cause other vascular diseases ( that is, other diseases of the arteries and veins ). [CLICK] 113,000 respiratory: Smoking can cause death from emphysema, chronic obstructive lung disease, pneumonia and influenza. It even makes people more likely to die from TB ( pulmonary tuberculosis ), because it damages the defences of the lungs against infection. [CLICK] 74,000 other: The “other” deaths from smoking shown here include some deaths from diseases such as stomach ulcer, and many of the deaths that were partly due to cancer, vascular or respiratory disease but did not get attributed to this on the death certificate. None of the deaths from fire or other non-medical causes have been attributed to smoking.
- About two thirds of smokers in the UK (70%) say they want to stop. 1 Nearly 80% have attempted to stop at least once, 2 with about 30% actively trying each year. 3 Cessation rates increase with age, starting at about 2% per year among smokers in their 20s and 30s, rising to about 4% per year among smokers in their late 40s and 50s. 4 Overall, 2% to 3% of all smokers manage to stop permanently each year. 5 The percentages shown on the slide mean that, of the current 13 million adult smokers in the UK, about 9 million want to stop and about 4 million will actually try each year with only about 300,000 succeeding in giving up for good. Many smokers require multiple attempts before succeeding. 5,6 Even people with potentially life-threatening smoking-related diseases continue to smoke: 40% of those who have had a laryngectomy try smoking again soon afterwards; 7 nearly 50% of lung cancer patients resume smoking within a year of surgery; 8 and 38% of smokers who suffer a heart attack return to smoking while still hospitalized. 9 1. Bridgwood A, Lilly R, Thomas M et al . Living in Britain : Results from the 1998 General Household Survey . Office for National Statistics, Social Survey Division. London: The Stationery Office, 2000. 2. Hansbro J, Bridgwood A, Morgan A, Hickman M. Health in England 1996: what people know, what people think, what people do. A survey of adults aged 16-74 in England. Office for National Statistics, Social Survey Division on behalf of the Health Education Authority. London: The Stationery Office, 1996. 3. West R. Getting serious about stopping smoking . A review of products, services and techniques. A report for No Smoking Day, 1997. 4. Stapleton J. Stat Methods Med Res 1998; 7 : 187-203. 5. Arnsten JH. Prim Psychiatry 1996; 3 : 27-30. 6. Rose JE. Ann Rev Med 1996; 47 : 493-507. 7. Himbury S, West R. Br Med J 1985; 291 : 514-15. 8. Davison G, Duffy M. Thorax 1982; 37 : 331-33. 9. Bigelow GE, Rand CS, Gross J et al . Smoking cessation and relapse among cardiac patients. In: Relapse and recovery in drug abuse . NIDA Research Monograph 72. Rockville, Maryland: US Department of Health & Human Services 1986: 167–71.
- The 1998 national smoking cessation guidelines made the following recommendations for the primary care team: 1 ASK : Patients should have their smoking status established on an ongoing basis. This should be recorded in the notes and the record should be kept up-to-date. ADVISE : All patients should be advised of the value of stopping and the health risks of continuing to smoke. The advice should be clear, firm and personalized. ASSIST : If the smoker would like to stop, help should be offered. This may include setting a ‘stop date’ when the smoker should stop completely, offering support such as self-help materials, together with pharmacological treatment as necessary. ARRANGE : Offer a follow up visit in about a week, and further visit after that if possible. Continue to offer support and check smoking status regularly. Refer to a specialist smoking cessation service if necessary. Primary care teams will differ in how the roles and responsibilities are divided. However, the nature of the doctor-patient relationship, with the respect people have for the doctor on health matters, means that the GP is likely to have a central role, at least in raising the issue and advising smokers to stop. 1 1. Raw M, McNeill A, West R. Thorax 1998; 53 (Suppl 5, Pt 1): S1-19.
- 1 This slide illustrates some of the short and long-term benefits of stopping smoking. After just 20 minutes of finishing a cigarette, blood pressure, heart rate and peripheral circulation begin to improve. After 8 hours without smoking, nicotine and carbon monoxide levels will fall by at least half, and oxygen levels return to normal. After 24 hours of stopping, nicotine will have been eliminated from the body. The sensations of taste and smell will start to improve. At 48 hours , carbon monoxide levels in the body should have returned to normal. The lungs start to clear out mucus and other smoking-related debris. The risk of a myocardial infarction (MI) also begins to fall. After 72 hours , breathing should become easier as airway passages in the lungs begin to relax. Energy levels will start to increase. Between 2 and 12 weeks after stopping, circulation improves generally improving ability to exercise and cope with sudden physical exertion. Between 3 and 9 months after stopping, coughing and wheezing should improve, and phlegm reduce. By one year , the risk of developing coronary heart disease is halved compared with someone who continues to smoke. The risk continues to drop over time — after 10 to 15 years it is similar to that for a person who has never smoked. Ten years after stopping , an ex-smoker’s risk of lung cancer is reduced to about half of that for a continuing smoker. The risk continues to decline with abstinence. The risk of stroke is similar to that for someone who has never smoked after 10 years of quitting.
- Smoking cessation is a highly cost-effective healthcare intervention, comparing favourably with many other common healthcare interventions. 1,2 To be successful, smoking cessation strategies need to address the overriding role of nicotine addiction in keeping smokers smoking, as well as the behavioural aspects of the disorder. 3 For this reason, the more effective approaches to smoking cessation involve simultaneously targeting of both aspects, using pharmacological intervention combined with some form of motivational support and advice. 4,5 It is well accepted that advice from a healthcare professional, even if brief, can increase smoking cessation rates. 6 NRT can also help some smokers to stop smoking by reducing nicotine withdrawal symptoms through weaning schedules; however, there are some considerations to its use. 4,7-9 The availability of new, effective and alternative pharmacological treatments for smoking cessation are clearly needed and will provide further impetus for healthcare professionals to help those smokers who are motivated to stop. 1. Parrott S, Godfrey C, Raw M et al . Thorax 1998; 53 (Suppl 5): S1-38. 2. Briggs AH, Gray AM. Health Technol Assess 1999; 3 : 1-134. 3. Leshner AI. Hosp Pract 1996; Oct 15 : 47-59. 4. Thompson GH, Hunter DA. Ann Pharmacother 1998; 32 : 1067-75. 5. Haxby DG. Treatment of nicotine dependence. Am J Health Sys Pharm 1995; 52 : 265-81. 6. Raw M, McNeill A, West R. Thorax 1998; 53 (Suppl 5): S1-19. 7. Fant RV, Owen LL, Henningfield JE. Primary Care Clin Office Pract 1999; 26 (3): 633-52. 8. Rennard SI, Daughton DM. J Resp Dis 1998; 19 (Suppl 8): S20-S25. 9. Benowitz NL. Drugs 1993; 45 : 157-70.
- Willpower alone is the most widely used method; however, as the slide shows, it is the least effective. 1 Self-help materials are a useful source of information but their effectiveness has not been extensively studied. Advice from a GP can increase quit rates—even very brief advice can result in 2% more smokers stopping (over no intervention), bringing 12-month cessation rates up to about 5%. 1,2 In general, the more intensive the overall intervention, the greater the likelihood of its success. Thus, the use of a pharmacological treatment in combination with some form of motivational support provides better cessation rates than either component alone and appears to be the most effective way of helping smokers to stop. 1 The Tobacco Advisory Group of the Royal College of Physicians has recently supported this complementary approach to treating nicotine addiction. 3 1. Parrott S, Godfrey C, Raw M et al . Thorax 1998; 53 (Suppl 5): S1-38. 2. Richmond, RL. Int J Tuberc Lung Dis 1999; 3 : 100-12. 3. Royal College of Physicians of London. Nicotine addiction in Britain: A report of the Tobacco Advisory Group of the Royal College of Physicians . London: Royal College of Physicians, 2000.
- Cochrane reports which are based on randomised trials with follow -up of at least 6 months follow-up. Aversive methods means trying to get the smoker to associate smoking with unpleasant experiences. To achieve that tablets with silver acetate has been tried, as the tablet cause an unpleasant taste when combined with smoking. There are two published randomised studies with 6 months follow-up with bio-chemical validation. No advantage over placebo.
- Aversion could also be achieved by suggestions given under hypnosis. This method could also strengthen a smoker’s self-confidence in stopping smoking. The scientific basis for determining whether or not hypnosis is effective in smoking cessation is very poor, because most published studies of hypnosis do not meet the criteria for scientific studies.(Usually they do not include a control group or have no biochemical validation.)