02.Smoking Cessation Pkb 2007(2)

7/23/2019 02.Smoking Cessation Pkb 2007(2)

1/42

SMOKING CESSATION:

What could be done?

IDA BAGUS NGURAH RAIul!ona"# D$%$&$on o' De(a"te!ent o'

Inte"nal Med$c$ne) Med$cal School o' Uda#anaUn$%e"&$t#* De(a"te!ent o' ul!onolo+# o'

Wan+a#a Ho&($tal) Den(a&a"


2/42


3/42

S!o,$n+ "oble! Wo"ld-$de

. Tobacco $& the &econd !a/o" cau&e o' death $n

the -o"ld0

. It $& cu""entl# "e&(on&$ble 'o" the death o' one $n

ten adult& -o"ld-$de 1about 2 !$ll$on death& each

#ea"30. I' cu""ent &!o,$n+ (atte"n& cont$nue) $t -$ll cau&e

&o!e 45 !$ll$on death& each #ea" b# 65650

. Hal' the (eo(le that &!o,e toda# 7that $& about825 !$ll$on (eo(le7 -$ll e%entuall# be ,$lled b#

tobacco0

Betther. J Thorax Onco 2007; 8 (Suppl):S140-S141


4/42

S!o,$n+ "e%alence 7 A&$a

WHO 2002

Count"# o(ulat$on1Sou"ce: WHO3

9 Men1Sou"ce:WHO3

9 MenS!o,e"

1Sou"ce:

WHO3

Ch$na 2;)62)555 24049 24)54>)555 24089 60=9

Indone&$a 146,860,000 49.9% 69.0%

Tha$land =8)58


5/42

S!o,$n+ $n Indone&$a

. Total a!ount o' &!o,e"& a"e 860;550555

(eo(le o" 8)5=9 !en and =);59 &!o,e"& ha%e been &!o,$n+ &$nce

4 #ea"& old and 46)>> 9 &$nce

ele!enta"# &chool6)tbl@a"t$,el

52)$d0ht!l


6/42

S!o,$n+ ead$n+ "e%entable

Cau&e o' D$&ea&e and Death4

6

Top 3 Smoking-Attributable Causes o !eat" in #S$1 ung &an&er

$' (s&"emi& "eart )isease

$3 C*+!Can&erung eukemia

arngeal A, A, C/'-4

*ral &aitp"arn2 sop"ageal

Stoma&" +an&reati&i)ne 5la))er

Ceri&al

Car)ioas&ular

(s&"emi& "eart )isease

Stroke 7as&ular )ementia

+erip"eral as&ular )isease6

Ab)ominal aorti& aneursm

espirator

C*+!

+neumonia

+oor ast"ma &ontrol

epro)u&tieo:-birt" :eig"t

+regnan& &ompli&ations

e)u&e) ertilit

Su))en (nant !eat" Sn)rome

*t"er

A)erse surgi&al out&omes:oun)

"ealing

;ip ra&tures

o:-bone )ensit

Catara&t

+epti& ul&er )iseaseu&leus

A&&umbens

#>?S

>(C*T(> @*

S*(>?

>(C*T(>

7TA

N$cot$ne Add$ct$on: Re$n'o"c$n+

Beha%$o"

TA : ent"al Te+!ental A"ea


10/42

Mechan$&! o' Act$on o' N$cot$ne $n

the Cent"al Ne"%ou& S#&te!

. >i&otine bin)s preerentiall to ni&otini& a&etl&"olinergi& nAC"/ re&eptors in

t"e &entral nerous sstem t"e primar is t"e 4' ni&otini& re&eptor in t"e

7entral Tegmental Area 7TA/

. Ater ni&otine bin)s to t"e 4' ni&otini& re&eptor in t"e 7TA, it results in a

release o )opamine in t"e >u&leus A&&umbens nA&&/ :"i&" is beliee) to be

linke) to re:ar)

=666=

4'

>i&otini&

e&eptor


11/42

. >i&otine bin)ing &auses an in&rease in

release o !opamine1,'

. !opamine gies eelings o pleasure an)

&almness1

. T"e !opamine )e&rease bet:een &igarettes

lea)s to :it")ra:al smptoms o irritabilit

an) stress1

. T"e smoker &raes >i&otine to release more

!opamine to restore pleasure an) &almness1

. Competitie bin)ing o >i&otine to ni&otini&

a&etl&"olinergi& re&eptors &auses

prolonge) a&tiation, )esensitiBation, an)

upregulation'

. As >i&otine leels )e&rease, re&eptors reert

to an open state &ausing "pere2&itabilitlea)ing to &raings1,'

1. aris . BMJ. '0043'8D'EE-'E9. '. +i&&iotto , et al. Nicotine and Tob Res. 1999D Suppl 'DS1'1-S1'.

!opamine

>i&otine

The C#cle o' N$cot$ne Add$ct$on


12/42

TOBACCO DEENDENCE

WHO ICD745: Mental and Beha%$ou"al D$&o"de"&

J4>) Mental and beha%$ou"al d$&o"de"& due to u&e tobacco

J4>05) Acu"e $nto$cat$on

J4>04) Ha"!'ul u&eJ4>06) De(endence nd"o!e

J4>0605) Tobacco u&e 1-h$ch eclude& J4>06 Tobacco

de(endence3


13/42

J4>06 Tobacco de(endence can be de'$ned

a$ a clu$ter o& !eha/oural5 cont/e5 an

ph"$olocal pheno'ena that e/elop a&terrepeate u$e an t"pcall" nclue a $tron e$re

to $'oe5 &&cult" n controlln t$ u$e5 per$$tn

n t$ u$e e$pte har'&ul con$e%uence$5 ncrea$e

tolerance to ncotne5 an (ph"$cal) 6thra6al$tate


14/42

Cot$n$ne e%el

. Hal'7l$'e o' n$cot$ne $& &ho"t) 6 h

. Cot$n$ne $& a !a/o" !etabol$te o' n$cot$ne)-$th a hal'7l$'e o' 42765 h $& "eco!!ended

. Can be anal#&ed '"o! blood (la&!a)&al$%a) u"$ne

. Non&!o,e") (la&!a concent"at$on o'

cot$n$ne@ L 42 n+0!4S!o,e"F& e%a"a+e le%el @ 655 n+0!41can"each 4)555 n+0!43

,tter et al. ' J ,pe' 2000; 11:21-28


15/42

Ehaled CO

. Non&!o,e") L = ((!

. S!o,e") 45765 ((!

. The hal'7l$'e o' CO $& = h

. Read$n+ $n the !o"n$n+ $& lo-e" than the

a'te"noon

. W$th$n 476 da#& a'te" the la&t c$+a"ette) theCO le%el -$ll be no"!al0

J'ene9-u9 et al. #he$t 2001; 11:1


16/42

ue&t$on Re&(on&e o$nt&

Ho- &oon a'te" #ou -ea, u( do #ou &!o,e#ou" '$"&t &$+a"ette?

W$th$n 2 !$n87(C*T(> !+>!>C @T>!/


17/42

>5 9 &!o,e"& ea+e" to &to(&!o,$n+0

ON 297459 can do $t-$thout hel(

40 Hu+he& R0 Ne- t"eat!ent& 'o" &!o,$n+ ce&&at$on0 CA Cance" Cl$n0 655525:4=


18/42

Mot$%at$on to +$%e u(

. Ho- $!(o"tant $& $t 'o" #ou to +$%e u(?

1&cale: 45753

. I' #ou -e"e to dec$de to &to( &!o,$n+)

ho- con'$dent a"e #ou that #ou -ould

&ucceed? 1&cale: 45753


19/42

SMOKING CESSATION

. SCHOOGICA AND BEHAIOURAINTERENTION:

Sel'7hel( ("o+"a!!e&

B"$e' ad%$ceCoun&ell$n+

. HARMACOOGICA TREATMENT:

N$cot$ne "e(lace!ent the"a(# 1NRT3Su&ta$ned7"elea&e bu("o($onNe- !ed$cat$on&: 3arenclne

Tonne$en et al. ,ur e$pr J 2007; 2:


20/42

N$cot$ne t"a&de"!al

(atche&

N$cot$ne che-$n+ +u!

N$cot$ne o"al tablet&

N$cot$ne o"al $nhale"

2 !+) 45 !+) 42 !+*48 h

> !+) 4= !+) 64 !+*6=

h 6!+) =!+

6 !+ &ubl$n+ualtablet 4 !+

loen+e 6

!+ and = !+ loen+e

45 !+ $nhalat$on

ca"t"$de) (lu& !outh($ece

502 !+ (e"

&("a# $nto each no&t"$l

N$cot$ne na&al &("a#

JORMUATION MARKETED RODUCT

A%a$lable n$cot$ne "e(lace!ent the"a(# 'o"!ulat$on&


21/42

All NRT 'o"!ulat$on&

N$cot$ne +u!

N$cot$ne (atch

N$cot$ne $nhale"N$cot$ne na&al &("a#

N$cot$ne &ubl$n+ual tablet*loen+e

= !+ +u! %e"&u& 6 !+ +u!

J$ed +u! %& ad l$b$t$u! +u!

Co!b$nat$on o' t-o NRT %& &$n+le NRT

Bu("o($on SR

40>> 140>7403

4088 1402740;3

40;4 140876053

604= 140=7


22/42

Bu("o($on SR

. Bel$e%ed to act d$"ectl# on the (ath-a#& $n theb"a$n "e&(on&$ble 'o" n$cot$ne de(endence and-$thd"a-al

. Reduce -$thd"a-al !to!& and c"a%$n+ 'o"c$+a"ette&

. Sta" u&$n+ 4 -ee, be'o"e &to(($n+ &!o,$n+

. 465 tablet cou"&e 41425 !+3 once a da# 'o" the

'$"&t < da# then 425 !+ tablet t-$ce a da# 'o" >7-ee,&7 can be cont$nued

. Non7n$cot$ne the"a(#

re$ler. J Thorax Onco 2007: 8 (Suppl): S1


23/42

a"en$cl$ne

$ l$ A H$ hl S l t$


24/42

a"en$cl$ne: A H$+hl# Select$%e

=6 Rece(to" a"t$al A+on$&t

40 Coe W et al0 "e&ented at the 44th Annual Meet$n+ and >th Eu"o(ean Con'e"ence o' the Soc$et# 'o"

Re&ea"ch on N$cot$ne and Tobacco0 6552060 $cc$otto MR et al0 *cotne To! e$.4Su((l 6:S4647S4620

B$nd$n+ o' n$cot$ne at the =6 n$cot$n$c "ece(to"$n the TA $& bel$e%ed to cau&e "elea&e o'do(a!$ne at the nAcc

a"en$cl$ne $& an =6 n$cot$n$c "ece(to" (a"t$ala+on$&t) a co!(ound -$th dual a+on$&t andanta+on$&t act$%$t$e&0Th$& $& bel$e%ed to "e&ult $n botha le&&e" a!ount o' do(a!$ne "elea&e '"o! the TAat the nAcc a& -ell a& the ("e%ent$on o' n$cot$neb$nd$n+ at the =6 "ece(to"&0

>i&otine7areni&line


25/42

7areni&line e&"anism o A&tionD

i&a& or Toba&&o !epen)en&e

. i&a& o areni&line in toba&&o)epen)en&e 5eliee) to result rom partial agonist a&tiit at

t"e 4' ni&otini& re&eptor

. 5 preenting bin)ing o ni&otine,areni&lineD e)u&es &raing an) :it")ra:al smptoms

agonist a&tiit/

+ro)u&es a re)u&tion o t"e re:ar)ing an)reinor&ing ee&ts o smoking antagonista&tiit/

C"ampi2 Summar o +ro)u&t C"ara&teristi&s. +iBer t), San):i&", #. '006.

.


26/42

E''ect o' a"en$cl$ne on Do(a!$ne

Relea&e $n the Nucleu& Accu!ben&

Rolle!a H et al0 *europhar'acolo".655>26:;27=0

>i&otine 0.3' mgkg s&

E

100

1'

10

1E

'00

-180 -1'0 -60 0 60 1'0 180 '40 300 360

Time minutes/

!opa

mine9eleasein

>.A&&umbens

%o

5asalF

S3

Nicotine 0.32 mg/kg

7areni&line 1 mgkg po

G >i&otine 0.3' mgkg s&

7areni&line 1 mgkg po

7areni&line 1

mgkg po

>i&otine 0.3' mgkg


27/42

A(a ha!batan uta!a #an+ d$"a&a,an do,te"

dala! !enolon+ (a&$en be"hent$ !e"o,o,?

3 "ambatan utama )alam meng"entikan rokokD

1. kurangna keinginankesa)aran pasien

'. A)iksi

3. pengaru" lingkunganPfzer Inc. STOP (Smoking:The Opinion o

A(a #an+ d$(e"lu,an (a"a do,te" untu, da(at


28/42

A(a #an+ d$(e"lu,an (a"a do,te" untu, da(at

!e!bantu (a&$en be"hent$ !e"o,o, leb$h

ba$,??

Menu"ut !e"e,a) ke"a)iran suatu obat ang lebi" eekti )aripa)a

obat-obat ang tela" terse)ia saat inia,an &an+at !e!bantu !e"e,a

dala! !enolon+ (a&$en untu, be"hent$ !e"o,o,

Pfzer Inc. STOP (Smoking:The Opinion o


29/42

Inclu&$on C"$te"$a

. Male o" 'e!ale out(at$ent c$+a"ette &!o,e"&4)6

. 4; to >2 #ea"& old4)6

. Mot$%ated to Qu$t &!o,$n+4)6

. 45 o" !o"e c$+a"ette&*da# du"$n+ the (a&t #ea" and o%e"the !onth ("$o" to &c"een$n+4)6

. No (e"$od o' ab&t$nence < !onth& $n the (a&t #ea"4)6

. J"ee o' &e"$ou& o" un&table d$&ea&e -$th$n (a&t 8 !onth&4)6

. No ("e%$ou& bu("o($on SR u&e4)6

. No othe" &!o,$n+ ce&&at$on ("oduct& -$th$n the (a&t

!onth4

40 o"enb# DE et al0 J0 655868:28787220


30/42

Co!(a"at$%e Stud$e& De&$+n4)6

Treatment +"ase >on-treatment +"ase

7areni&line 1 mg t:i&e )ailH

5upropion 10 mg t:i&e )ailH

+la&ebo

S&reening7isit

5aselinean)omiBation

Ieek 1' Ieek '

C T T C T T C T C T CC C C C C C C C C C C C C

I I I I I I I I I I I

13 16 '0 '4 '8 3' 36 40 44 48 '

5 I I I I I I I I I I I I

1 ' 3 4 6 E 8 9 10 11 1'

>on-p"arma&ologi& @ollo:-upTreatment +erio)

an)omiBationTarget Juit !ate

VT$t"ated du"$n+ Wee, 40

B@ba&el$ne W@-ee, C@cl$n$c %$&$t T@tele(hone contact

40 o"enb# DE et al0 J0 655868:28787220

T-o) $dent$call#7de&$+ned) ha&e < e''$cac# t"$al&

a"en$cl$ne 405 !+ t-$ce da$l# %e"&u&

(lacebo o" bu("o($on SR 425 !+ t-$ce da$l#

46 -ee,& o' act$%e t"eat!ent 'ollo-ed b#

=5 -ee,& o' non7(ha"!acolo+$c 'ollo-7u(


31/42

ain *ut&ome easures

Continuous abstinen&e rate CA/ rom smoking

K &onirme) b e2"ale) C* leels L 10 ppm

or a )eine) perio) at t"e inal 4 :ks o treatment

M )uring ollo:-up

A non&!o,e"F& CO %alue L= ((!0

The hal' l$'e $& = h0A'te" 476 da#& a'te" the la&t c$+a"ette) the CO le%el -$ll

be no"!al0

J'ene9-u9 et al. #he$t 2001; 11:1


32/42


33/42

Cont$nuou& Ab&t$nence Rate&:

Wee,& to 26 ooled Anal#&e&

52

45

42

65

62


34/42

(n&rease) Appetite

(nsomnia

estlessness

>egatie Ae&t

Craing elie #pon Smoking

+s&"ologi& e:ar)

Smoking Satisa&tion

a"en$cl$ne S$+n$'$cantl# Reduced S#!(to!&o' C"a%$n+) W$thd"a-al) and the Re$n'o"c$n+

E''ect& o' S!o,$n+ %e"&u& lacebo4)6

S&ore signii&antl lower&ompare) :it" pla&ebo S&ore signii&antl higher&ompare) :it" pla&ebo

#rge to Smoke >IS/

Stu)

''Stu)

11Stu) ''

Stu)

11

5upropion7areni&line

Iit")ra:al

einor&ement

Craing

40 o"enb# DE et al0 J0 655868:28787220

MNWS@M$nne&ota N$cot$ne W$thd"a-al Scale

Ma$ntenance o' Ab&t$nence


35/42

Ieek '4 Ieek '

Ma$ntenance o' Ab&t$nence

1Etended The"a(#3 Stud# De&$+n

*pen-abel+"ase

>on-Treatment@ollo:-#p +"ase

7areni&line 1 mg t:i&e )ail

+la&ebo

C T C T C T C T C

I I I I I I I I I

' '6 '8 3' 36 40 44 48 '

>on-+"arma&ologi& @ollo:-#p

!ouble-5lin)/

C C C C CC C C C C C C C C C C

I I I I I

13 14 16 '0 '4

5 I I I I I I I I I I

1 ' 3 4 6 E 8 10 1'

!ouble-5lin)

Treatment*pen-abel Treatment

an)omiBationTarget Juit !ate

Ieek 1'

7areni&line 1 mg 5(!

Titrate)/

!ouble-5lin)+"ase

5aseline

B@ ba&el$ne) W@-ee,) C@cl$n$c %$&$t) T@tele(hone contact

Ton&tad S et al0 J0 655868:8=7>40

To inestigate t"e beneit o an a))itional

1'-:eek )osing or subOe&ts :"o a&"iee)

abstinen&e )uring t"e last E )as o open-

label areni&line treatment Ieek 1'/

o$nt "e%alence o' Ab&t$nence


36/42

Ton&tad S) et al0 J0 655868:8=7>40

o$nt "e%alence o' Ab&t$nence

J"o! Wee,& 6 to 46

O(en7label T"eat!ent ha&e

Wee,

Ab&t$nence193


37/42

Cont$nuou& Ab&t$nence Rate& J"o!

Wee, 46 to Wee, 26

AR@%a"en$cl$ne) BO@(lacebo

Ton&tad S et al0 J0 655868:8=7>40

Ieek

AR: =


38/42

+"arma&okineti&s o 7areni&line

. ;al-lie P'4 "ours

. Cma2 :it"in 3 to 4 "ours

. Stea)-state rea&"e) :it"in 4 )as

. *ral bioaailabilit unae&te) b oo)

. 9'% o )rug is e2&rete) un&"ange)

. >o in"ibition o &to&"rome +40 enBmes

. >o &lini&all meaningul )rug intera&tions i)entiie)

. >o )ose restri&tions in patients :it" "epati& insui&ien&

. !ose a)Oustment reQuire) or seere renal impairment, ma

be &onsi)ere) or mo)erate renal impairment

. >o )osage a)Oustment is ne&essar or el)erl patients :it"outrenal impairment

1. C"ampi2 Summar o +ro)u&t C"ara&teristi&s. +iBer t), San):i&", #. '006.


39/42

a"en$cl$ne

. Sta"t u&$n+ 4 -ee, be'o"e &to(($n+

&!o,$n+

. 502 !+ O once a da# 'o" da#& 47


40/42

WHAT COUD BE DONE?


41/42

2 A& and 2 R& Jo"!ula&

. ASK

. ADISE

. ASSESS

. ASSIST

. ARRANGE

. Rele%ance

. R$&,

. Re-a"d

. Roadbloc,&

. Re(et$t$on

re$ler. J Thorax Onco 2007: 8 (Suppl): S1


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T;A> R*#

02.Smoking Cessation Pkb 2007(2)

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Transcript of 02.Smoking Cessation Pkb 2007(2)