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Tobacco Cessation Methodologies

The presentation by Dr.M.S.Chandragupta, Chief Dental Surgeon, Dr. Gupta's Dental Specialities Centre, deals with Tobacco Cessation Methodologies.

Tobacco is the number one killer in the world and kills around 9 lakh people annually in India alone. The victims succumb to tobacco in the most productive years of their life. To curb this issue the World Health Organization has brought out a public health legal treaty called ‘Frame Work Convention on Tobacco Control (FCTC)’ which more than 176 countries have signed and ratified the same. India has signed in the year 2005 and initiated measures to bring down the demand and supply of tobacco in India as mandated by the FCTC. India has the second highest number of tobacco users in the world, at an alarming number of 274 million users (GATS Report, 2010) and it is high time we act together to make India Tobacco Free for a healthier and wealthier tomorrow

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Tobacco Cessation Methodologies

  1. 1. IS IT EASY TO QUIT TOBACCO???????If a non-smoker is being questioned, he says YESconfidently…But for a tobacco user, he says it is very difficult to comeout of the habit……………Any idea why is it so??????????Because there is something called as Addiction ! ! !
  2. 2. WHAT IS ADDICTION? A mal-adaptive pattern of substance use,leading to clinically significant impairmentor distress Tolerance to a substance Withdrawal from a substance Taking a substance in larger amount or overa longer period of time than intended.So what causes addiction……….
  3. 3. NICOTINEWHAT DOES IT DO? Tobacco dependence is caused by Nicotine, which is aneuro –chemical, anatomical and molecular basis of itsaction is that of a psycho-stimulantSites of action In Brain: midbrain, brain stem, cerebral cortex, Other parts of body (muscles, adrenal glands, heart, etc.).Mechanism Of Action Through its nAChRS(nicotine acetyl choline receptors) Bycausing secretion of dopamine, it produces reinforcing,stimulant and dependence properties. By acting on non-dopaminergic sites, it produces positiverewarding actions and some of the withdrawal symptoms.
  4. 4. Nicotine - Dependence
  5. 5.  The resultant release of acetylcholine,noradrenaline, serotonin, vasopressin, etc., itcauses:1.An immediate rise in blood pressure,2. Increase in heart, respiratory and pulse rates &3. Rise in blood sugar levelsIn addition, it leads to alertness (arousal,concentration and stress reactions),memoryenhancement and muscles contractions.
  6. 6. Ywhat happens if u don’t quit????????????what happens if u quit????????????How to encounter it or HOW TO QUIT?????
  8. 8. WHAT HAPPENS ONCE U QUIT???After 20 Minutes • Blood Pressure and Pulse drop to a normal rate.• Temperature of hands and feet increases to normalAfter 8 Hours • Carbon Monoxide level in the blood drops to normal.• Oxygen level in the blood goes up to normalAfter 24 Hours • Chance of Heart Attack starts going downAfter 48 Hours • Nerve endings start growing again.• Ability to taste and smell begins to improve.2 weeks to 3 months • Circulation improves.• Walking gets easier• Lung function improves up to 30%1 month to 9 months • Coughing, sinus congestion, tiredness and shortage ofbreath decrease.• Cilia grow back in the lungs to better handle mucus, cleanthe lungs and reduce infection.After 1 year • Risk of coronary artery disease is half that of a smoker.After 5 years • Lung Cancer death rate goes down by one half• Risk of stroke becomes the same as a non-smoker.• Risk of cancer in the mouth, throat, esophagus, bladder,kidney and pancreas goes down.
  9. 9. • Craving for tobacco• Reason: Reduced levels of nicotine• Duration: Few days, up to months & years sometimes• Dizziness• Reason: Increased flow of oxygen to the brain• Duration: Few days• Insomnia• Reason: An emotional and mental response to withdrawal besides the disturbedsleep pattern• Duration: 1 week• Headaches• Reason: Increased blood flow to the brain; and, tension to stay quit• Duration: 1 to 2 weeks• Chest discomfort• Reason: Excessive mucus flow which blocks the airways and increased musculareffort to cough out the mucus and tar deposited in lungs• Duration: 1 to 3 weeksWITHDRAWAL SYPTOMS
  10. 10. • Constipation• Reason: Transient reduction in intestinal movement; and, the psychological triggerto move the bowels is missing• 1 to 2 weeks• Irritability• Reason: Due to craving for nicotine• Duration: 2 to 4 weeks• Fatigue• Reason: Inability to get the “kick/ stimulation” from nicotine• Duration: 2 to 4 weeks• Cough or nasal drip• Reason: Revived cilia action to clear the respiratory passages• Duration: Few weeks• Lack of concentration• Reason: Biochemical dysfunction due to relative deficiency of nicotine• Duration: Few weeks• Hunger• Reason: The appetite suppressant action of tobacco is no more there.• Duration: Up to several Weeks
  11. 11. HOW TO QUIT?????PSYCHO BEHAVIOURAL THERAPYPHARMACOTHERAPY•Nicotine Replacement Therapy (NRT)•Non Nicotine Replacement Therapy
  12. 12. PSYCHO BEHAVIOURAL THERAPY• Brief clinical interventions (i.e., when a doctor takes 10minutes or less to deliver advice and assistance aboutquitting)• Counseling (e.g., individual, group, or telephonecounseling)• Counseling along with medicationTCCMEDIAGOVERNMENTNGO
  13. 13. 5ASAsk-about tobacco useAdvise- to quitAssess- commitment and barriers tochangeAssist-users committed to changeArrange-follow up to monitor progress
  14. 14. • Be positive -you should not get blogged down by negativethoughts• Distract yourself - engage yourself in some physical activity orsome hobby that you enjoy doing• Eat healthy - Eats lots of fruits, vegetables, and whole grains,enjoy a low-fat diet• Pamper yourself - when you quit do not neglect yourself asthis is the time when you need to pamper yourself.• Walk everyday - to stay healthy and fight cravings• Drink lot of fluids -will keep you hydrated, help you detoxmore quickly and work as a craving buster• Know quitting is long and hard - quitting is a long process asyour body is coping with the withdrawal symptoms- you need tobe patient• Reward yourself –on smoke free day
  15. 15. NICOTINE REPLACEMENT THERAPY (NRT)Nicotine GumsNicotine PatchesNicotine LozengesNicotine InhalersNicotine Nasal Sprays
  16. 16. NICOTINE REPLACEMENT THERAPY (NRT)Dosage anddurationSide effects Contraindicationsa. Nicotine gum For 1-24cigarettes/bidis -2mg gum (up to 24pieces/day) for 12weeks.For ≥25 cigarettes/bidis – 4mg gum (upto 24 pieces/day) for12 weeksChewers need abouthalf or a quarter ofthe dose asprescribed forsmokers.Mouth soreness,burning in themouth, throatirritation, dyspepsia,nausea, vomiting,hiccups and excesssalivationGastricUlcers,myocardialinfarction or strokein the past twoweeks or poorlycontrolled CVD
  18. 18. Please note that the TobaccoCessation therapy is team effort of agroup of professionalsIts Dangerous to take medicinewithout the guidance of TrainedDoctors
  19. 19. Dosage anddurationSide effects Contraindicationb. Nicotine patch 21mg/24 hours for 4weeks then15mg/24 hours for 2weeks then 7mg/ 24hours for 2 weeks.Local skin reaction,insomniamyocardial infarctionor stroke in the pasttwo weeks or poorlycontrolled CVDc.Nicotine inhaler 6-16 cartridges/dayfor 6 monthsLocal irritation ofmouth and throat- As above -d.nicotine nasalspray1-2 doses / hr for 3to 6 monthsNasal irritation andIrritation of throat,coughing andwatering of eyes.- As above -
  20. 20. NON NICOTINE REPLACEMENT THERAPYFirst Line•Bupropion•Varenicline•FluoxetineSecond-line•Clonidine•nortriptyline
  21. 21. Bupropion :•It is a smoking cessation aid.•The drug is an antidepressant that has both dopaminergic andadrenergic actions as its primary pharmacological action isto reduce the craving of smokers for their cigarettes.•After 1 -2 weeks of Bupropion treatment a person isready to quit. DOSE: 150MG/DAY x 1 TO 3 days300mg/day x 7 to 12 weeks
  22. 22.  Side effects: GI upsets, agitation,restlessness, insomnia, headache, loweringof seizure threshold, etc. Contraindications: H/O Allergy, CNS tumors,Uncontrolled seizures, Hepatic diseases,Patients on MonoAmineOxidase(antidepressent) drugs or undergoingunsupervised alcohol withdrawal, Pregnancy,lactation, Children below 18 years , etc
  23. 23. Varenicline: This is a partial nicotine agonist that selectively binds to the alpha (4) andbeta (2) nicotinic acetylcholine receptors in the brain. It lessens the physical pleasure fromtaking in nicotine and helps lessen the symptoms of nicotine craving. Tobacco use may bestopped one week after initiating treatment with VareniclineDOSE : 0.5 mg / day x 1 to 3 days0.5mg BID x 4-7 days1 mg BID x 12 weeks
  24. 24.  Side effects: GI upsets, depression, restlessness,insomnia, headache, bad dreams, suicidalideations, etc. Contraindications: Pregnant women, children andpeople with H/O mental illnesses. Stop immediatelyif changes in moods, & behavior, agitation, suicidalideation occur
  25. 25. THE WHO FRAMEWORK CONVENTION ONTOBACCO CONTOL (FCTC) The FCTC is the first international treaty negotiatedunder the auspices of the WHO, aimed at curbingtobacco related deaths and disease. In a historic leap towards promoting public health,the Govt. of India ratified the FCTC on FEB 5th2004. India was the 7th country to ratify theconvention. This exhibits a strong commitment to tobaccocontrol, in light of the fact that India is a majortobacco consuming and producing nation There is totally 38 articles.
  26. 26. FCTC - ARTICLE 14Demand reduction measures concerning tobaccodependence and cessation1. Each Party shall develop and disseminate appropriate, comprehensiveand integrated guidelines based on scientific evidence and bestpractices, taking into account national circumstances and priorities, andshall take effective measures to promote cessation of tobacco use andadequate treatment for tobacco dependence.2. Towards this end, each Party shall endeavour to:(a) design and implement effective programmes aimed at promoting thecessation of tobacco use, in such locations as educational institutions,health care facilities, workplaces and sporting environments;
  27. 27. (b) include diagnosis and treatment of tobacco dependence andcounselling services on cessation of tobacco use in national health andeducation programmes, plans and strategies, with the participation ofhealth workers, community workers and social workers as appropriate(c) establish in health care facilities and rehabilitation centres programmesfor diagnosing, counselling, preventing and treating tobaccodependence(d) collaborate with other Parties to facilitate accessibility and affordabilityfor treatment of tobacco dependence including pharmaceutical productspursuant to Article 22.Such products and their constituents may include medicines, productsused to administer medicines and diagnostics when appropriate