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Smoking cessation

Smoking cessation ( or quitting smoking or simply quitting ) is the
 process of discontinuing tobacco smoking ( Wikipedia ).

How common ? Tobacco smoking is a worldwide threat to human life According to WHO there are 1100 million smokers worldwide which constitutes one-third of the global population aged 15 yrs and above
 ( of these 73 % are in developing nations ) Smoking is still the single biggest cause of preventable illnesses , cancer and avoidable death in the UK Smoking prevalence in the UK has fallen from 51 % of men and 41 % of women in 1971 to 17.7 % of women and 14.1 % of women in 2016 An estimated 16 % of all deaths in 2015 were attributed to smoking Treating smoking related illnesses is estimated t cost the NHS 2.5 billion pounds a year and the wider cost to the society is about 12.7 billion pounds a year In the UK number of people seeking help via stop smoking services has declined for reasons not known In the US smoking accounts for approximately 1 in 5 every death According to ICMR India is the 4th largest produced otf tobacco and 2nd in the world after China in cigarette and bidi production 12 % of all adult deaths worldwide are attributable to tobacco use Appoximately 10 % of pregnant women smoke in the US and the UK.

Nicotine –Tobacco smoke contains more than 6000 chemicals including nicotine tar , carbon monoxide , methoprene , propylene glycol , benzopyrene butane , cadmium , acetone , ammonia ,lead , benzene, formaldehyde et out of which 79 are known carcinogens Nicotine is readily absorbed through the skin and lungs and and is metabolized by the lungs , liver and kidneys Nicotine acts via 3 major mechanisms (1) ganglionic transmission (2) nicotinic acetylcholine receptors ( nAChRs ) on chromaffin cells via catecholamines (3) CNS stimalation of nAChRs nAChRs are expressed by both neuronal and non-neuronal cells throughout the body Nicotine acutely increases activity in the pre-frontal cortex and visual systems Various neurotransmitters are released- important in drug induced reward Nicotine causes an increased oxidative stress and neuronal apoptosis , DNA damage , reactive oxygen species and lipid peroxide increase Nicotine via nAChR receptors causes a wide range of acute and long term effects on organ systems , cell multiplication and apoptosis throughout the body Nicotine is one of the most addictive agent – considered to be as addictive as cocaine or heroin.

Drug delivery system –Cigarettes contain finely cut tobacco wrapped in a thin paper Tobacco and aaditives are burned and the smoke inhaled to consume the nicotine The system is very efficient Nicotine is absorbed and reaches the brain within 10 seconds The dose of nicotine varies based on depth of inhalation and the number of puffs but is estimated to deliver 1 to 1.5 mg of nicotine / cigarette and it take about 5-10 minutes to consume a cigarette A single puff of a cigarette exposes the smoker to more than 10 ( to the power 15 ) free radicals in the gas phase and additional radicals and oxidants in the tar phase.

Very brief advice on smoking- If the person smokes deliver VBA which can
 be done in 30 seconds. Marketed as 30 seconds to save a life and is supported by meta-analysis.ASK

 and record smoking status- smoker , 
ex smoker or a non-smoker.ADVICE
 
on the importance of quitting -tell that stopping smoking is the single most important thing that you can do for your health now and in future – Help is available. ACT

on patients response . Build confidence ,
 give information , prescribe and refer if available.

History-Ask questions to judge dependence on nicotine and the possibility of withdrawal symptoms Two main questions which can help judge dependence are
1 how many cigarettes do they smoke
2 how quickly after waking do they smoke the first cigarette

Tools can also be used to judge dependence – please find it under links and resources
 Ask about previous attempts at quitting Ask about current smoking habits
how much
when 
what
other nicotine products Identify people who may be at higher risk of tobacco related harm for e.g
people with mental health issues
substance misuse
h/o cancer for e.g lung cancer
people with underlying medical conditions like asthma , COPD , CVD , diabetes People who are more dependent on nicotine – refer to professional smoking cessation service and they will require a higher level of support , a higher dose of medication and and several attempts to quit.

Harmful effects of smoking –
Cancer-Nicotine has biologic effects on cells important for initiation and progression of cancer. Smoking is responsible for 87 % of lung cancer deaths ( 90 % in men and 80 % in women ). Compared to non smokers men and women who smoke are 25 times more likely to die from lung cancer. Other than lung cancer 1 out of 3 cancer deaths is smoking related


RespiratoryMost cases of COPD are due to smoking and 80 % of deaths due to COPD are attributable to smoking. Also increased risk pneumonia and cancer as discussed above.

CVS –Major independent risk factor for CAD , cerebrovascular disease and total atherosclerotic CV disease. Smoking triples the risk of dying from heart disease among middle age men and women.
2/3rd of deaths due to IHD amogst smokers are attributable to their smoking
Risk of ischaemic stroke is nearly doubled
Smoking accounts for nearly 11 % of all stroke deaths.

Pregnancy related –maternal DVT and pre-eclampsia pre-term birth pre-term rupture of membranes placental abruption placenta praevia ectopic pregnancy miscarriage.

Fetal complications –behavioural problems , learning difficulties , reduced educational performance , childhood respiratory problems diabetes or obesity in later life infant mortality sudden infant death syndrome ( SIDP ) Still birth , birth defects like cleft lip LBW, IUGR.

Skin- ageing , wrinkles , wound infection Hair- hair loss Mouth and pharynx- cancer , gum disease Stomach- cancer , ulcer Pancreas cancer Women – cervical cancer , early menopause , irregular and painful periods Men – ED Bone – osteoporosis Diabetes Hearing loss More likely to get influenza and more likely to experience severe symptoms when they get it.

Nicotine replacement therapy- Available in various form – please refer to BNF for dosing and duration and other prescribing information
 Gum Inhalator Lozenge Nasal spray Oral spray Sublingual tablet Transdermal patch.

Bupropion-Bupropion Hcl is the hydrochoride salt of the aminoketone bupropion with anti-depressant activity and for potential use in promoting smoking cessation and improving sexual desire It is weak blocker of the neuronal uptake of serotonin , dopamine and NE and is a central nicotinic acetylcholine receptor antagonist.

Vareniciline is a partial agonist of the nicotine acetylcholine receptor ( nAChR ) subtype alpha4beta2 As an AChR partial agonist varenciline attenuates the craving and withdrawal symptoms that occur with abstinence from nicotine but is not habit-forming itself Prescription only medication to treat smoking addiction It is the first FDA approved nicotinic receptor partial agonist.

LINKS AND RESOURCES

PATIENT INFORMATION

One-stop site from NHS https://www.nhs.uk/live-well/quit-smoking/nhs-stop-smoking-services-help-you-quit/

12 week guide to Champix from Pfizer https://www.pfizerpro.co.uk/sites/default/files/patient_booklet_flat_pp-gip-gbr-1766_reformatted.pdf

Fact sheets from Action against Smoking https://ash.org.uk/fact-sheets/

Patient check for nicotine dependence https://www.stop-dependance.ch/cgi-bin/tobacco/en/quests/dependance_en.pl?begin

Fagerstorm test for nicotine dependence https://www.hse.ie/eng/about/who/tobaccocontrol/resources/fagerstrom-test-for-nicotine-dependence.pdf

Help me quit Wales https://www.helpmequit.wales/

Quithelp ( by Pfizer ) https://www.quitwithhelp.co.uk/?gclid=Cj0KCQjwpfHzBRCiARIsAHHzyZqTpmJ2-lXK3J5XU1ht6kKURkydAjeLxd6zS6cNFOFPfvd-ZvCr59kaAnZBEALw_wcB&gclsrc=aw.ds

For patients in USA https://betobaccofree.hhs.gov/quit-now/index.html

References

  1. PubChem Vareniciline and Bupripion
  2. CKS NHS Smoking cessation March 2018
  3. Health Harms from Smoking and Other Tobacco use from Campaign for Tobacco Free Kids.
  4. Harmful effects of nicotine by Pankaj Chaturvedi et al Indian Journal of medical and paediatric oncology https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4363846/
  5. Review article Smoking Cessation a update Raj Kumar and Rajendra Prasad via Medindia
  6. NICE Guideline Stop Smoking Interventions and Services March 2018
  7. Nicotine and the Developing Human A neglected element in the electronic cigarette debate Lucinda J England et al American Journal of Preventative Medicine 2015
  8. Action on smoking and health – stopping smoking leaflet for patients via www. ash.org.uk

 

 

 

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