Brief Interventation 3As, 5As and 5Rs Diseases Impact
Transcript of Brief Interventation 3As, 5As and 5Rs Diseases Impact
Brief Interventation 3As, 5As and 5RsDiseases Impact
TOPIC 5
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52MANAGEMENT IN QUIT SMOKING PROGRAMME Training Module For Health Care Providers
LEARNING OBJECTIVE
Brie
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3As,
5As
and
5Rs
Dis
ease
s Im
pact
• Workflowpathwayinpromotingtheservicebasedonclinicalpractice.• AssessmentfornicotineaddictionbasedonFagerstromformtestevaluation.• ApplicationofWHObriefclinicalinterventionincludingthemethodtodeliverthe3As,5Asand5Rs
interventionatprimarycarelevel.
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Recommendations
• Tobacco dependence is a chronic disease – requires repeatedinterventionandmultipleattemptstoquit
• Clinicians and health care delivery systems - identify and documenttobaccousestatusandtreatEVERYtobaccouserseeninahealthcaresetting
• To provide at least a brief intervention to every tobaccouser at eachhealthcarevisit
• Ifatobaccousercurrentlyisunwillingtomakeaquitattempt,cliniciansshouldusethemotivationaltreatments
Assessmentoftobaccoused&willingnesstoquit
MOH CPG On Treatment Of Tobacco Use And Dependence 2003
Theassessmentsaretolookfor:1. Levelofaddiction(usingFagerstromQuestionnairesandnumberof
cigarettesmoked)2. Readinessforquitting
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53MANAGEMENT IN QUIT SMOKING PROGRAMME Training Module For Health Care Providers
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Fagerström’stestforNicotineDependence
Question Answers (markyouralternative)
Howsoonafteryouwakeupdoyousmokeyourfirstcigarette
Within5minutes6–30minutes31-60minutesAfter60minutes
3______2______1______0______
Doyoufinditdifficulttorefrainfromsmokinginplaceswhereitisforbiddene.g.inchurch,atthelibrary,incinema,etc.?
YesNo
1______0______
Whichcigarettewouldyouhatemosttogiveup?
ThefirstoneinThemorning?Allothers?
1______0______
Howmanycigarettesdoyousmokeperday?
10orless11-2021-3031ormore
0_____1_____2_____3_____
Doyousmokemorefrequentlyduringthefirsthoursafterwakingthanduringtherestoftheday?
YesNo
1______0______
Doyousmokeifyouaresoillthatyouareinbedmostoftheday?
YesNo
1______0______
0–3LowNicotineDependence4–6ModerateNicotineDependence7-10HighNicotineDependence
Total:
LevelOfNicotineAddictionFagestromtestScore 0-3 4-6 7-10
No.ofcigarette <10 10-25 >25
Nicotinedependence Low Moderate High
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Algorithmfortreatingtobaccouse
Relapsepreventioninterventionarenotnecessaryinthecaseoftheadultwhohasnotusedtobaccoformanyyears
FlowChartOfClinicalPracticeGuidelinesOnManagementOfTobaccoUseAndDependence
doespatientnowusetobacco
promotemotivationto
quit
preventrelapse
encouragecontinuedabstinence
provideapproriatetobaccodependence
counseling&treatments
ispatientnowwaiting
toquit
didpatientonceusetobacco
YES
YES YES
Relapse
Abstinent
Non-user
NO
NO NO
GeneralPopulation
Adviseom
smokinghazards
Advicetoquit
Currentusers
exuser
NO YES
Patientnowwillingtoquit
Patientsstllunwillingtoquit
Releaseprevention
Assistquitting
Advicetoquit
Promotemotivationtoquit
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AskscreenforTobaccouse
Patientspresenttoahealthcaresetting
Arrangefollowup
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BriefClinicalIntervention
• Briefclinicalinterventionbythephysicianincreasesquitrateseffectively• Itisvitaltochangeclinicalcultureandpracticepatternstoensurethat
everypatientwhousestobaccois identifiedandofferedcounseling&treatment
• So,everytobaccousershouldbeofferedatleastabriefinterventionasthishasbeenproventoincreaseoveralltobaccoabstinencerates
• Studies have shown that individual counselling resulted in higherabstinenceratesascomparedtogrouporphonecounsellingandself-help
• Briefinterventionintheprimarycaresettingaredesignedtobebriefandminimalclinician/healthcareprovidertimeisrequired
AAAofBriefClinicalIntervention
A1.AskabouttobaccouseA2.AdvisetoquitA3.Actonpatient’sresponse 1. ApplySTARor 2. ReferpatienttoQclinic
Tobedeliveredtoeachtobaccouser,regardlessofhisorherwillingnesstoquit
Helpthepatientwithaquitplan(applySTAR)
• Setaquitdate.Ideally,thequitdateshouldbewithin2weeks• Tell family, friends, and coworkers about quitting, and request
understandingandsupport• Anticipatechallengestotheupcomingquitattempt,particularlyduring
thecriticalfirstfewweeks,theseincludenicotinewithdrawalsymptoms• Remove tobaccoproducts fromyourenvironment–makeyourhome
smoke-free
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5AsofBriefClinicalIntervention
A1.AskabouttobaccouseA2.AdvisetoquitA3.AssesswillingnesstoquitA4.AssistinquitattemptA5.Arrangefollow-up
A2:ADVISEclienttoquit
Inaclear,strongandpersonalizedmannerurgeeverytobaccousertoquit“Benefitofquitting”“Impactofsmoking”
A1:ASKabouttobaccouseIdentifyanddocumenttobaccousestatusforeverypatientateveryvisit“Areyoucurrentlyasmoker?“,“Doyoueversmokebefore?“Expandthevitalsignstoincludetobaccouseoruseanalternativeuniversalidentificationsystem(e.g.stickersonpatientcharts)
VitalSignsBloodPressure:__________________________________________Pulse:_____________________Weight:_____________________Temperature:_________________________________________RespiratoryRate:______________________________________TobaccoUse:(circleone)CurrentFormerNever
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A3:ASSESSWillingnesstoquit“Areyouwillingtoquit““Areyoureadytoquitnoworwithin6months“
• Thereisevidencethatthelikelihoodofsuccessinanattempttoquitisunrelated to thesmoker’sexpressed interest inquitting in theperiodleadinguptotheattempt–unplannedattemptstoquitareaslikely(orevenmorelikely)tobeassuccessfulasplannedattempts
• Thus, there is benefit in encouragingall smokers to considerquittingwhenevertheopportunityarises
RapidlyAssessingaSmoker’sStageofChange
Doyoucurrentlysmoke
pre-comtemplation
comtemplation preparation action maintenance
haveyouconsideredquiting
smoking
haveyouconsideredquitingsmoking
Non-smoking
haveyoueversmokedinyour
lifetime
areyouthinkingaboutquitingin
thenext6monthsorhavetriedto
quitfor≥24hoursthepastyear
YES NO
NO
NO YES <6MO >6MO
YES NOBr
ief I
nter
vent
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n 3A
s, 5
As a
nd 5
Rs D
isea
ses
Impa
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A4:ASSISTinquitattempt
1. Forthepatientwillingtomakeaquitattempt -Providecounseling&medication2. Forpatientsunwillingtoquit -Provideinterventionsdesignedtoincreasefuturequitattempts(5R’s)
A5:ARRANGEforfollow–up1. Forthepatientwillingtomakeaquitattempt - Arrangeforfollow-upcontacts,beginningwithinthefirstweek
afterthequitdate2. Forpatientsunwillingtomakeaquitattempt - Addresstobaccodependenceandwillingnesstoquitatnextclinic
visit3. Follow-upsarerecommendedweeklywithinthefirstmonth,and
theneverytwoweeksforthe2ndand3rdmonth,andmonthlyafterthatupto6months
4. Forthosewhosuccessfullyquit,schedulefollow-upcontact,eitherinpersonorviatelephone
Helpthepatientwithaquitplan(applySTAR)
1. Setaquitdate.Ideally,thequitdateshouldbewithin2weeks2. Tellfamily,friends,andcoworkersaboutquitting,andrequest
understandingandsupport3. Anticipatechallengestotheupcomingquitattempt,particularly
duringthecriticalfirstfewweeks,theseincludenicotinewithdrawalsymptoms
4. Removetobaccoproductsfromyourenvironment–makeyourhomesmoke-free
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Duringfollow-up
Askwhetherclienttotallyabstain
• Ifyes:praiseandcongratulate• Ifno:askwhy;motivate• Askforwithdrawalsymptomsifany• Whatdoyoudotoovercomewithdrawal• FindoutwhetherclientuseNRT/oralmedicationcorrectly
ForThePatientUnwillingToQuit(5R)Provide5R’s strategies– toenhancemotivation to increase futurequitattempts
• Relevance• Risks• Rewards• Roadblocks• Repetition
Relevance
• Encouragethepatienttoindicatewhyquittingispersonallyrelevant• Motivational informationhasthegreatest impact if it is relevant toa
patient’sdiseasestatusorrisk, familyorsocialsituation(e.g.,havingchildreninthehome),healthconcernsetc
Risks
Askthepatienttoidentifypotentialnegativeconsequencesoftobaccouse• Short-termrisks:exacerbationofasthma,harmtopregnancy,
impotenceandinfertility• Longtermrisks:Heartattacks,strokes,COPDandlungcancer• Environmentalrisks:1. Increasedriskoflungcancerandheartdiseaseinspouses2. Increasedriskforasthmaandrespiratoryinfectionsinchildrenof
smokers3. Higherratesofsmokingbychildrenoftobaccousers
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Rewards
1. Askthepatienttoidentifypotentialbenefitsofstoppingtobaccouse2. Examplesofrewardsfollow: - Improvedhealth - Improvedsenseofsmell - Savemoney - Setagoodexampleforchildren - Havehealthierbabiesandchildren - Performbetterinphysicalactivities - Reducedwrinkling/agingofskin
Repetition
1. Themotivationalinterventionshouldberepeatedeverytimeanunmotivatedpatientvisitstheclinicsetting
2. Tobaccouserswhohavefailedinpreviousquitattemptsshouldbetoldthatmostpeoplemakerepeatedquitattemptsbeforetheyaresuccessful
SLIDE
23 Roadblocks
1. Askthepatienttoidentifybarrierstoquittingandnoteelementsoftreatment(problemsolving,pharmacotherapy)thatcouldaddressbarriers)
2. Typicalbarriersmightinclude: - Withdrawalsymptoms - Fearoffailure - Weightgain - Lackofsupport - Depression - Enjoymentoftobacco - Costoftreatment
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TOPIC 6
Management of Quit Smoking Services at
Health Clinic
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LEARNING OBJECTIVE
Managem
entofQ
uitSmokingService
satHealthClinic
• TechiniqueinmanagingthedocumentationprocessandretensysteminQuitSmoking Services.Appointmentsystemmechanismismentionedinthistopicaswellasdefaulter tracingmechanism.• Work flow chart process for Quit Smoking Services is elaborated in this topic comprehensively for
efficientservice.• Screening procedure based on the 3As, 5Rs and 5As technique are stated. Scoring for the level of
willingnessforquittersismentionedinthistopicduringthefirstappointmentwiththeclient.
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QuitSmokingServices
StopSmokingService is includingthepromotionandclinicalservices forsmokerclienttostopsmoking.
Objective
GeneralObjectiveToproduceahealthsocietyandfreefromcigarettesmokeandalsoliveinanoptimumhealthylifestyle
SpecificObjective
1. Educatethesmokergroupaboutthedangerousandnegativesideeffectfromsmokingandalsoawarenessamongthem.
2. Toallowallthesmoketostopsmokingbasedontherighttechniqueintheguidelinemodulewhichhasbeenproduced.
3. Helpthesmokertostopsmokingwithaproperstepandplanned.4. Enablesmokerswhoquitsmokingremainasnon–smoker.5. Encouragethenon–smokerssocietytoremaincleanfromsmoking.
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Managem
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uitSmokingService
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QuitSmokingServicePolicies
1. AllhealthclinicsmusthavetheQuitSmokingServicesetting.2. All the clinic staffs are required to undergo the course on how the
managementoftheserviceisdeliver.3. All health clinics must provide the screening (BSSK form) service in
findingclient.4. HealthClinicmustfullyequippedwiththetoolsforoperatingthequit
smokingactivity.
OrganizationChartoftheQuitSmokingService
PKD
HealthClinic
FamilyMedicineSpecialist
Dietician MedicalOfficer
MedicalAssistant StaffNurse
CommunityNurse
ClinisAttendant
Pharmacist Dentist
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Managem
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uitSmokingService
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Recordanddocumentation1. Allnewclientswhoisagreedtojointhequitsmokingprogrammust
registerintheregistrationbookbeforegoingthroughtheinterventionprogramme.
2. AllquitsmokingclientmusthavetheirownfolderorQuitSmokingGuideline.
3. Eachfollowupthatbegivenmustberecordedintheregistrationbook.4. Retenmustbeupdatedandcompiledatthecliniclevel,DistrictOffice
level,HealthStateOfficeandMinistryofHealth(MoH).
1. TreatmentroomforQuitSmokingService
Usetheconsultationortreatmentroomwhichalreadyexisted.
2. Equipmentandtools a. Sphygomomanometerand
Stethoscope b. Weightmachineandheight
measurement. c. BMIchart d. PeakFlowMeter e. CO2Analyser f. ECGmachine g. ComputerandPrinter h. Spirometer(ifavailable)
3. Medication NicotinePatch a. Nicotinepatch7mg b. Nicotinepatch14mg c. Nicotinepatch21mg
NicotineGum a. Nicotinegum2mg b. Nicotinegum4mg Varenicline(Champix) c. Varenicline0.5mg/tablet a. Varenicline1mg/tablet Lozenges c. Lozenges2mg a. Lozenges4mg
4. Guidelineandmanual a. Smallrecordbook/brochure–
QuitSmoking b. ModuleforQuitSmoking c. GuidelineforQuitSmoking d. ClinicalPracticeGuideline
(CPG)onTreatmentofTobacco SmokingandDependence
e. BrochureofQuitSmoking f. FlipchartofQuitSmoking
(educationmaterial)
5.Documentation a. Registrationbook i. Newcase ii. Followupcase b. Client’squitsmokingfolder c. RetenKBM1/2012,Reten
KBM2/2012,RetenKBM 3/2012,RetenKBM4/2012 danRetenKBM5/2012
6. Educationmaterialfacility a. Healthclinicmusthavethe
materialforeducationin operatingthequitsmoking servicesandactivities.
b. Materialforeducation: i. Posterofdangerofsmoking ii. Broucherofdangerofsmoking iii.Visualaudio iv.Buntingofquitsmokingservice v. Healthfactmaterial(magazine)
regardingsmoking.
ListofequipmentandtoolfortheQuitSmokingService
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65MANAGEMENT IN QUIT SMOKING PROGRAMME Training Module For Health Care Providers
Managem
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uitSmokingService
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EarlyscreeningforQuitSmokingService
1. ScreeningflowchartforQuitSmokingService2. ScreeningworkprocessforQuitSmokingService3. PrincipleofQuitSmokingServicemanagement–3As,5As,5Rs4. Screeningforthelevelofreadiness/willingnessamongclientwhokeen
toquitsmoking.
Referappendix2(topic6:ManagementofQuitSmokingServicesatHealthClinic
ScreeningworkprocessforQuitSmokingClient
WorkProcess Standard Action Equipment
Identifyclient ClientfromBSSKscreening,PKSandPPKPChronicdiseasecaseWalk–incaseHealthcampDentalclinicReferalfromGovementOffice/school/Privateoffice
PPP/JK/JM/PPKP/PKAPKSenforcementUPK
Relatedscreeningform
PengendalianKlien
Non–smokerclientAdvise/healtheducation
Ex–smokerclientAdvise/healtheducationPreventionfrom‘relapse’
SmokerIfagreedtostoprefertotheinchargeofficerforfurtherintervention.Ifnotagreed,advise/healtheducation(5Rprinciple)
MOHEOPPPJKJM
SOPQuitSmokingService
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uitSmokingService
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QuitSmokingPrinciples
3Asprinciples1.Ask • Ask and record the history regarding the cigarette consumption by client
2.Advise • Advise the patient regarding the smoking hazard and also the advantageofstopsmoking.
3.Action • Recordalltheinformationinthepatient’srecordandreferthepatient toQuitSmokingServiceUnit.
5Asprinciples
Brief introduction to the smokerclient1. Ask • Ask and record the history
regarding the cigarette consumptionbyclient
2. Advise • Advisethepatientregarding
thesmokinghazardandalsothe advantageofstopsmoking.
3. Assess • Evaluatetheaddictionleveland
the willingness spirit of the clientregardingstopsmoking.
4. Assist • Helptheclienttostopsmoking
5. Arrange • Do the preparation for the
clientattheQuitSmokingServiceUnit.
5RsprinciplesIt is a intervention which help tomotivate the client and prevent thepatientfromnotsmokeagain.
1. Relevance • Relate the client’s personal
interestsifhestopsmokingeg: If the client want to have childrenandsoon.
2. Risks • Explain the negative impact of
tobaccousebasedonshortand longtermeffect.
3. Rewards • Imagine if there are more
rewardsandbenefitiftheclient stopsmoking.
4. Roadblocks • Identifytheclient’sobstacle
5. Repetition • Motivation has to be repeat
several times which helps to maintainthespirit inclientand givesupportcontinouslyeven thereisfailure.
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ScreeningTheLevelOfWillingnessForQuitSmoking
SCORE:LevelOfWillingnessForQuitSmoking1. Pre-contemplationstage `NO’toquestion1
2. Contemplationstage `Yes’toquestion1dan`No’otherquestion
3. Preparation `Yes’toallthequestions
SCORE:Pre-contemplationstage
Yes No Question
1 Areyouinterestedtoquitsmokingwithinthese6months?
2 Doyouplantoquitsmokingnextmonth?
3 Haveyouevertrytoquitsmokingwithinthe12monthsago?
SCORE:Preparationstage
Yes No Question
1 Areyouinterestedtoquitsmokingwithinthese6months?
2 Doyouplantoquitsmokingnextmonth?
3 Haveyouevertrytoquitsmokingwithinthe12monthsago?
RetenManagementAssessmentandMonitoring
Monitoringtheretenisbasedon:1. Monthlyreten2. 6monthlyreten3. Trainingtostaffregardingthequitsmokingservicesforatleastoncea
year.
Monitoredindicators:1. Totalclientwhichalreadyregisteredforquitsmokingservicesinthe
registrationbook.2. Totalofclientwhoalreadyquitedsmoking.3. Totalrateforclientwhoalreadyquitsmoking.
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ListofretenfortheQuitSmokingServicesatHealthClinicNo Documenttitle Documentseries
1. NewclientretenmonthlyQuitSmokingClinic(HealthClinic)
BPKK/KBM/1/2012
2. Clientthatalreadyquitsmokingreten(HealthClinic) BPKK/KBM/2/2012
3. 6monthlyreten:totalclientthanquitedsmoking(HealthClinic)
BPKK/KBM/3/2012
4. 6monthlyreten:Totalrateofquitsmoking BPKK/KBM/4/2012
5. Yearlyreten:TrainingforHealthProviderforquitsmokingservices
BPKK/KBM/5/2012
MonthlyReten1. Totalnewclientwhichregisteredinthequitsmokingservicesforthat
particularmonth.2. Totalclientthatalreadyquitsmokingforthatparticularmonth.
6monthlyreten1. Totalclientforquitsmokingserviceswithin6months(January–Junand
July–December)2. Totalquitratefor6months(January–JunandJuly–December)3. Quit rateforyearly is theaverageratefrom(January– Junand July–
December)4. Defaulter
QuitRatefor6months(January–JunandJuly–December)
Quitrate Totalclientthatalreadyquitmorethan6monthsx100% Totalregisteredsmoker
YearlyQuitRateisaveragefromJanuarytillJuneandJulytillDecember
TotalclientthatalreadyquitsmokingfromcurrentyearJanuarytillJunex100%TotalclientthatalreadyregisteredfromJulytillDecemberpreviousyear
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69MANAGEMENT IN QUIT SMOKING PROGRAMME Training Module For Health Care Providers
Managem
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Transmissionofthereten• RetenmustsendtoDistrictOfficebefore5thdayofthemonth.• RetenmustsendtoStateOfficebefore8thdayofevery6month.• RetenmustsendtoFamilyHealthDevelopmentDivision,Ministryof
Healthevery15thJulyand15Januaryoftheyear.
Defination
1. Regeisteredclient • Totalclientthatregisteredinthequitsmokingservicesregistration
book.
2. Defaulter • Clientwhodonotcomeforthefirstappoinmentandfailedtomakean
appointmentwithin1weekfromthedategiven.
3. Clientthatquitsmoking • Morethan6months
4. Terminationofcase • Clientthatfailedtoattendthe3appointmentsgiven
Appointmentsystemanddefaultertracing
• Appointmentbook• Recordbookfordateandtimeofcallshasbeenmade-–defaulter
tracing
Recordstorage• Registrationbookforquitsmokingservice(BlueBook)• Clinicmonthlyreten–todespatchtotheMedicalAssistantOfficerat
DistrictlevelusingtheMinistryofHealthformat.
ClientDifficulty• Lackofmotivationtoquitsmoking• Negativemoodanddepression• Strongaddictionandprolonged• Gainedweight• Nostrongmotivation
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Overcomesteps
Problem Overcomesteps
Lackofmotivationtoquitsmoking
Reschedulethetreatmentappointmnet
Proactivecaunselingviatelephone
Identifythesupportingteam
Referral
Negativemoodanddepression
Caunselling(depression)
Prescribetherightmedication
Referral
Strongaddictionandprolonged
Usethepharmacologytechniqueforlongtermtreatment
Careintheward
Gainedweight Adviseonhealthdiet
Increasethephysicalactivity
Refertodietician
Nostrongmotivation Motivation:5RapproachRelevanceRisksRewardsRoadblocksRepetition
Fatwa• 23rd March 1995, 23rd March 1995, Fatwa Chairboard memberDialgueand37thNationalCouncilforIslamicAffairshasdecidedthatsmokingisHARAMfromtheIslamperspectiveandisamustforeashmuslimtoavoidit.
• Kedah,Perlis,P.PinangSelangor,W.PersekutuandanPahang
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TOPIC 7
Promotion and counseling - Quit Smoking programme
in Health Clinic Tanglin
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72MANAGEMENT IN QUIT SMOKING PROGRAMME Training Module For Health Care Providers
LEARNING OBJECTIVE
Prom
otionandcounseliin
g-Q
uitSmokingprogrammeinHealthClinicTanglin
• ComprehensiveplanforpromotingtheQuitSmokingServiceinthehealthcliniciswellexplainedinthistopic.Promotionplaysabigroleininfluencingtheclientandtheaccessibilitytotheservicewithshouldbeconvinientandaccessibetoclient.
• Techniqueindraggingtheclienttoquitsmokingwillbementionedinthistopicincludingtheeducationmaterial.
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Objectives
• Createawarenessregardingthedangersofsmoking• Provideknowledgeandskillsforsmokerstoquitsmoking.• Provide treatment and rehabilitation to smokers who intend to quit
smoking.• Encouragethequitterstomaintaintheirquitstatus
StaffForQuitSmokingClinic
• Doctor • StaffNurse• MedicalAssistant • CommunityNurse• Pharmacist
SuitableplaceforQclinic
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Prom
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WhatDoYouNeedInTheQuitSmokingClinic
• Relevantforms• Sphygomomanometer• Weighingscale• CarbonMonoxideBreathAnalyzerSet• Champix,Nrt,VitaminC,Vaseline• Appointmentbook
Serviceschedule
Selectsuitabledays
Day Time
Wednesday 2pm-4pm
Fridays8am-12noon
2.45pm-4pm
WhereToPromote
1. IntheTriage2. IntheProcedureRoom3. IntheConsultationRoom4. DuringDOTStreatmentsession
5. InthetreatmentRoom6. IntheFundusCameraRoom7. InthePharmacy8. Fromallplacestothequitclinic*Fromallplacestothequitclinic
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Prom
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uitSmokingprogrammeinHealthClinicTanglin
QUITSMOKINGCLINIC
DotsTreatment
Dr’sRoom
Medicalcheckup
Triage QuitSmokingBooth
Pharmacy
FundoscopyRoom
TreatmentRoom
BloodRoom
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Prom
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SLIDE6
SLIDE7
SLIDE9
SLIDE8
Whowillpromote?
1. Doctor2. Nurse3. MedicalAssistant4. Pharmacist5. ClinicAttendance6. Allstaffintheclinic
Howtopromote
A-Askthepatient“Sirdoyousmoke?”B-BriefInterventionC-Cessation
Pleaseapply3As,5Asand5Rsconcept***
PromotePharmacotherapy
• Gum• Inhaler• Patches• Champix• TreatmentIsFreeOfCharge
Promoteclinicdays
Walkinappointment
Day Time
Wednesday 2-4pm
Friday 8am–4pm(officehours)
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SLIDE10
SLIDE11
WorkProcessInQuitSmokingClinic
PromotionforQuitSmoking
TAHNIAH!!ANDABERSEDIAUNTUKBERHENTIMEROKOK
KlinikBerhentiMerokokKKTanglinRabu:2-4petangJumaat:8pagi-4petang
Nama:I/C:NamaStaffPromosi:Tarikh:S/NSWINDER-0132064377
Newsoftwaredonatedbyumquitsmokingsystem
• Startedabout2yearsback• onlyclinicinmalaysiawiththissystem• ifanyonewantstodoaresearch• Theycandoonline.
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SLIDE13
SLIDE14
SLIDE15
FagerstromTest(SmokingAddictionLevelTest)Score:
0-3LOW 4-5MODERATE>5HIGH
RoutineScreeningDoneOn
Everyvisit1. BloodPressure2. PulseRateHeightOnFirstVisit3. Weight4. MeasuringOfCarbonMonoxideLevel5. IndividualCounselling6. GroupCounselling
FindAQuitBuddy
1. Chancesareyouknowanothersmokerwhowantstoquit.2. Suggesttotheothersmokerthatyouwillhelpeachotherto(dousethe
flames)forever.3. Studiesshowthatsmokerswhopatnerwithaquitbuddyaremore
successful,ratherthanquittingontheirown.
Advisetoclients• Throwawayallthings• Associatedwithsmoking• Nobuying,beggingandrefuse• Offerofcigarettes• Informfamilymembersand
Friends• Avoidgoingtosmokingareas
• Avoidcaffeineateddrinksandalcohol
• Avoidoldsmokingbuddiesgetsupport
• Spendmoretimeinplacesthatbansmokinge.gCinemas,shoppingcenters
• Indulgeinanewhobby
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SLIDE17
SLIDE18
WhatHappensWhenYouQuit?
• Coughandrunningnose• Skinonthelipswillpeeloff• Swellingandbleedingofgums• Ulcermouth• Tingglingsensations• Sleepdisturbance• Increaseappetite
• Feellightheaded• Constipation.• Angry,irritatedmoodswings• Frustration• Restlessness• Chestpain• Bodyaches• Nighttimeawakenings
Fightingwithdrawal
• Strongurge-3minutes• Deepbreathing• 5minutesexcersice• Drinkplentyofwater8-10
glasses• Washfaceandhands• Coldbath
• Munchsomething• Keephandsbusy• Followrulingofredlight(divert
yourthinking)
PositiveEffectsOfExercise
• Reducestress• Increasestamina• Increasedfeelingsofwellbeing
andimprovedhealth• Weightloss
• Improvedmuscletoneandphysicalappearance
• Increasedself-esteemandsenseofaccomplishment
• Improvedsleep
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19TheBenefitsOfQuitting
Withinhours
8hours1. Nicotineandcarbonmonoxide
levelshalved2. Bloodoxygenlevelsreturnto
normal
24hoursCarbonmonoxideeliminatedfromthebody
48hours1. Nicotineeliminatedfromthebody2. Tastebudsstarttorecover
Withinmonths
1month1. Appearanceimproves2. Skinlosesgreyishpallorandless
wrinkled
3. Regenerationofrespiratoryciliastarts
4. Withdrawalsymptomshavestopped
3–9monthscoughingandwheezingdecline
Withinyears5years1. Theriskofaheartattack2. Reducesbyhalf
10years1. Theriskoflungcancerhalved2. Savemoney3. Home,car,clothing,andbreath
willsmellbetter.4. Setagoodexampletoyour
children.
Noofciggratesperday 5 10 20 30 40
Day1quitsmoking 2.50 5.00 10.00 15.00 20.00
1weekquitsmoking 17.50 35.00 70.00 105.00 140.00
1monthquitsmoking 70.00 140.00 280.00 420.00 560.00
1yearquitsmoking 840.00 1680.00 3360.00 5040.00 6720.00
5yearsquitsmoking 4200.00 8400.00 16,800 25,200 33,6004
10yearsquitsmoking 8400.00 16,800 33,600 50,400 67,200
SLIDE
20FATWA23rdMarch1995,23rdMarch1995,FatwaChairboardmemberDialgueand37thNationalCouncilforIslamicAffairshasdecidedthatsmokingisHARAMfromtheIslamperspectiveandisamustforeachmuslimtoavoidit.
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SLIDE22
SLIDE23
Clients are given nicotine replacement therapy to fight theirwithdrawalsymptoms:1. Champix2. Vitaminc3. Vaselineforlips
Criteria
a. Smokerswhoaremotivatedtoquitb. Smokingadultsaged>18yearsand<60yrs.c. Alcoholintake<3unitsperweekd. Notaddictedtoanyotherdrugsotherthannicotinee. Notpregnantorplanningtogetpregnantorlactating.f. Notonanypsychiatryfollowuportakinganyantidepressant
medicationsg. Nohistoryoffitsorepilepsy
Date:
Meetalltheinclusioncriteria:(allyes)No Criteria YES/NO1. Smokerswhoaremotivatedtoquit2. Smokingadultsaged>18yearsand<60yearsold3. SubjectnotonVareniclinebefore
4. Subjectspreviouslyonotherpharmacotherapybuthaverelapsedafter6months
5. Alcoholintake<3units/week
6. Notaddictedtoanyotherdrugs(otherthannicotine)
Meetallexclusioncriteria:(allno)No Criteria YES/NO
1. Subjectsinwhomvareniclinemaybetakeninamannerthatisnotaccordingtotheapprovedlocalproductdocument
2. Pregnantorplanningtogetpregnantorlactating3. Subjectsunderthecareofpsychiatryand/ortaking
antidepressantmedication4. Subjectswithknownhypersensitivitytovarenicline
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1. Date:
2. Vitalsigns -Notdone
SittingBP:…………………..
Pulse:…………………..
3. Nicotineuseinventory -NotDone
Hasthesubjectsmokedanycigarettes(evenapuff)inthelast7days?a) Yesb) No
Hasthesubjectusedanyothernicotine-containingproducts(e.g.nicotinepatch,gum,nasalspray,lozenges,pipe,cigars,chew,snuff)inthelast7days?a) Yesb) No
CarbonMonoxideBreathAnalyzerReadingSignificantneuropsychiatricbehaviouralscreen:
If you, the patient, their family or caregiver notice agitation, depressedmood, or changes in behavior that are not typical or develop suicidalthoughtsoractionsbythepatient,STOPtakingCHAMPIXandseehis/herdoctor.Motivationlevel:Low:GiveMotivationHigh:GiveChampix
SLIDE
24CHAMPIXtreatment
• Day1toDay3-0.5mgdaily• Day4toDay7-0.5mgBDX4days• 1mgbdx11weeks
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SLIDE26
SLIDE27
Remindertotheclients
Onedaybeforetheirappointment1stweekfollowup• Enquireaboutquitstatus• Praisethepatient• Anywithdrawals• Anyotherproblems• EnquirecorrectusageofNRT• Givenextappointment
Incentives
• Incentivesforthededicatedstaffofquitclinic• Staffwhopromotesthemostnumberofpatientstothequitclinicwill
begivenincentivesin2013
Vision
By2020tobaccowillnolongerbeamajorpublichealthconcern.InMalaysia,wheredecreasingnationalprevalenceoftobacco.Attributeddiseaseandmotalitywillcontinuouslydecline
82MANAGEMENT IN QUIT SMOKING PROGRAMME Training Module For Health Care Providers
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TOPIC 8
Pharmacological Intervention in Smoking
Cessation
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LEARNING OBJECTIVE
Pharmacologica
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• Pharmacologytherapyisoneofthemethodsinreleasingtheaddictionlevelinsmokerbesidemotivationorcounsellingsession.Therearefewofmedicationwhichavailableatthehealthclinicforsmokingcessationwithdifferentmethodofintakeroutes.
• Sideeffectfromeachdrugwhichyouprescribedwillbeexplainedinthistopic.Therefore,physicianmayknowwhichdrugisworkthebestandsuitthepatient.Theeffectivenessofthetreatmentandtheoutcomeofeachdrugarementionedattheendofthetopic.
SLIDE1
SLIDE2
SLIDE3
Outline
Attheendofthispresentation,participantsshouldbeableto:
1. Discuss latest evidence for pharmacologic intervention in smokingcessation
2. Explainthechoice,useandmonitoringofagentsforsmokingcessation
Whichonetouse?
1. Efficacy2. Safety3. Suitability4. Cost
NRT1. 111trialswithover40,000participants.2. Riskratio(RR)ofabstinenceforanyformofNRTrelativetocontrolwas
1.58(95%confidenceinterval[CI]:1.50to1.66).3. PooledRRforeachtype: - 1.43(95%CI:1.33to1.53,53trials)forgum - 1.66(95%CI:1.53to1.81,41trials)forpatch - 1.90(95%CI:1.36to2.67,4trials)forinhaler - 2.00(95%CI:1.63to2.45,6trials)forlozenges - 2.02(95%CI:1.49to3.73,4trials)fornasalspray.
CochraneDatabaseSystRev.2008Jan23;(1):CD000146.Nicotine replacement therapy forsmokingcessation.SteadLF,PereraR,BullenC,MantD,LancasterT
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SLIDE5
SLIDE6
Gum–thingstotellyourpatients
1. Chewitintherightway(itsnotlikeregularchewinggum)
2. Aciddrinksreducedamountavailableforabsorption
3. Newflavoursofgumaremorepalatable
4. Useenoughofit:about10-15piecesaday,hourly
5. Recommenduseforatleast3months
Usingenough
1. 1030smokerwhoquitforatleast2weeksinatrialofnicotinelozenges2. 28-dayscontinuousabstinenceat6-weeksfollow-upwaspositively
correlatedwithincreasedNRTuse3. EachoneadditionalpieceofNRTusedincreasetheoddsofquittingby10%4. Similareffectscanbeexpectedwithnicotinegum
ShiffmanS.Addiction2007,102(5)809-14
Transdermalpatch1. 16and24hourspatches2. High,mediumandlowdoses3. Recommenduseforsome3months4. 24hours patchesmay cause sleep disturbances
Patches–thingstotellyourpatients1. Newpatcheachmorning/night2. Onupperarm,sideoftorso,hairless partofbody3. Do not put on the same place, especiallyifrednessoccurs
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SLIDE8
Nicotineinhaler
Inhaler/Inhalator
1. Nicotine is not inhaled into lungs (but absorbed across the buccalmucosa)
2. Takessome30minutestoreachplateau3. Recommend
puffingcontinuouslyforsome10-20minutesQH.
4. 10puffsequalonepufffromcigarette.
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SLIDE10
SLIDE11
Lozenges
1. Weeks1through6:onelozengeevery1to2hours2. Weeks7through9:onelozengeevery2to4hours3. Weeks10through12:onelozengeevery4to8hours4. Donotusemorethanfivelozengesin6hoursormorethan20lozenges/
day
Howtotake1. Placethelozengeinthemouthandallowittodissolveslowly(20–30
minutes).2. Awarm,tinglingsensationmaybefelt(nicotinereleased).3. TominimizetheriskofADR(nausea,hiccupsandheartburn),donot
cheworswallow.4. Todecreasemouthirritation,occasionallymovethelozengetodifferent
areaswithinthemouth.
ChoosinganNRTproduct
1. Explanationofthedifferentproductsusuallyadequate2. Howeveronestudy*foundthatNRTpreferencesbasedonexplanations
changedaftersampling3. NRTsamplingmayleadtobetterchoiceandtreatmentcompliance
*Schneideratal.NTR(2008),10,179-186
Howdoyoudecideonthedose?
1. Cigaretteconsumptionisnotalwaysagoodguide,why?2. Mostpeoplecanstartonfullstrengthpatches3. Doseoforalproductcanbedeterminedbytimetofirstcigarette
(TTFC): • Smokeswithin30minutesofwakinguse4mggum • Smokersafter30minutesofwakinguse2mggum
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Cautionsandcommonsideeffectsassociatedwithnicotine replacementtherapyMedication Cautions Sideeffects
Nicotinegum CautionwithdenturesDon’tdrinkacidicbeveragesduringuse
Mouthsorenessstomachaches
Nicotineinhaler Mayirritatemouth/throatatfirst(butimproveswithuse)Don’tdrinkacidicbeveragesduringuse
Localirritationofmouthandthroat
Nicotinenasalspray NotforpatientswithasthmaMayirritatenose(improvesovertime)Maycausedependence
Nasalirritation
Nicotinelozenges Donoteatordrink15minutesbeforeorduringuseOnelozengesatatimeLimit20–24hours
HiccupsCoughHeartburn
Nicotinepatch Donotuseifyouhavesevereezcemaorpsoriasis
Localskinirritationinsomia
FioreMC,JaenRC,BakerTB,etal.ClinicalPracticeGuideline:Treatingtobaccouseanddependece:2008Update.Rockville,MD:USdepartmentofHealthandHumanServices.PublicHealthService;2008.
SLIDE13
Safetyissues
• NRT is safe to use in patients with stable cardiovascular disease.(StrengthA)
• NRT should be usedwith caution in patientswho have had a recentmyocardial infarction, unstable angina, severe arrhythmias or recentcerebrovascularevents.(StrengthC)
• UseofNRTshouldbeconsideredwhenapregnantwomanisotherwiseunable to quit. Intermittent NRT is preferred to patches (lower totaldailynicotinedose).(StrengthC)
ZwarN,etal.TheRoyalAustralianCollegeofGeneralPractitioners,2011
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SLIDE16
Higherdegreeofnicotinereplacement1. Therearemodestdatatoshowthathigherdegreeofnicotine
replacementisassociatedwithgreaterquitrates2. Morehighlydependentsmokersaremorelikelytoquitwhentheyuse
highdosegum(4mg)versuslowerdose(2mg)gum – RR=1.85,95%CI:1.30-2.5013. Similarresultsareseenwiththelozenge2
1. SteadLF,PereraR,BullenC,MantD,LancasterT.Nicotinereplacementtherapyforsmokingcessation.CochraneDatabaseSystRev2008(1)
2. ShiffmanS,DreslerCM,HajekP,GilburtSJ,TargettDA,StrahsKR.Efficacyofanicotinelozengeforsmokingcessation.ArchInternMed2002;162(11):1267-76
Higherdosepatches• Sevenstudiescomparedhigherdosepatches(e.g.44mg/24hours)with
standarddoses(21mg/24hours)• Overalltherewasasmallincreaseinlong-termquitrates(RR=1.15,
95%CI:1.01-1.30)
SteadLF,PereraR,BullenC,MantD,LancasterT.Nicotinereplacementtherapyforsmokingcessation.CochraneDatabaseSystRev2008(1)
CombinationStrategies1. CombiningtwoformsofNRT(patchplusoralform,suchaslozengeor gum)hasbeenshowntobemoreefficaciousthanasingleformof nicotinereplacement.2. 6trialscomparingcombinationwithsingleNRTshowsadvantageof combinationuse – RR=1.35(95%CI:1.11-1.63)
Patch-providesbackgroundcravingrelief + Intermittentdosingproduct-forcontrolof‘breakthroughcarving’
SteadLF,etal.Nicotinereplacementtherapyforsmokingcessation.CochraneDatabaseofSystematicReviews2008,Issue1.Art.No:CD000146.DOI:10.1002/14651858.CD000146.pub3.
FioreMC,BaileyWC,CohenSJ,etal.Treatingtobaccouseanddependence:clinicalpracticeguideline.Rockville,MD:UnitedStatesDepartmentofHealthandHumanServices,2000.
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SLIDE19
SLIDE18
• Thepatchprovidesasteadybackgroundnicotinelevelandtheoralformsprovidereliefforbreakthroughcravingsasneeded.
• UsecombinedNRTifsmokersareunabletoquitusingoneNRTproductalone,orexperiencecravingsusingonlyoneformofNRT.
• NRTpatchand2mggumor2mg lozenge is licensed (e.g.,Australia)forsmokerswhohaverelapsedinthepastorwhoexperiencecravingsusingonlyoneformofNRT.
ZwarN,etal.TheRoyalAustralianCollegeofGeneralPractitioners,2011.
SafetyofcombinationNRTuse
• IncidenceofadverseeventswithcombinationNRT isnotsignificantlygreaterthanthatwithsingleNRTuse.
• DataconsistentwithsafetydatashowingfavourableriskbenefitofNRToverwiderangeofdosesandsituations.
• Smokerscapableoftiteratingtheirnicotineintake.
Referappendix2,Topic8
Combination
Combinationtherapy
Patch(longterm;>14weeks)+adlibNRT(gumorspray)
3 3.6(2.5–5.2) 36.5(28.6–45.3)
Patch+BuproplanSR 3 2.5(1.9–3.4) 28.9(23.5–35.1)
Patch+Nortriptyline 2 2.3(1.3–4.2) 27.3(17.2–40.4)
Patch+inhaler 2 2.2(1.3–3.6) 25.8(17.4–36.5)
FioreMC,BaileyWC,CohenSJ,etal.Treatingtobaccouseanddependence:clinicalpracticeguideline.Rockville,MD:UnitedStatesDepartmentofHealthandHumanServices,2000.
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SLIDE21
SLIDE22
Pre-cessationNRTpatch
• Meta-analysisoffourstudies• Pre-treatmentwith21mg/24hourpatchesfor2weeks(3studies)or4
weeks(1study)• 6-monthsabstinenceOR=2.2(CI=1.5-3.2)
ShiffmanS,FergusonSG.Nicotinepatchtherapypriortoquittingsmoking:ameta-analysis.Addiction2008;103:557–63.
CutDownthenStop
• Nicotinegumandinhalerapprovedforusepriortostoppingsmoking.• Forsmokersnotintendingtostopimmediately.• Thegoalistoreducecigarettes-per-dayby50%overupto6-months.• Followthisbystoppingsmoking.• Ameta-analysisfoundthatreducingcigarettessmokedbeforequitday
vs.quittingabruptly,withnopriorreduction,producedcomparablequitrates.
LindsonN,AveyardP,HughesJR.Reductionversusabruptcessationinsmokerswhowanttoquit.CochraneDatabaseofSystematicReviews2010,Issue3.Art.No:CD008033.DOI:10.1002/14651858.CD008033.pub2
NRTassistedreductioninpeoplewhodon’twanttoquitabruptly• SystematicreviewofsevenRCTsinvolving2767smokersnotwillingor
abletostopabruptly• NRT-assistedreductionresultsinincreasedquittingandreduction
comparedtoplaceboOutcomes EventRates NNT(CI)
Smokingabstinencefor6months 6.8%vs.3.3% 29(15-90)
Sustainedsmokingreduction 6.1%vs.1.6% 23(12-48)
MooreD,AveyardP,ConnockM,WangD,Fry-SmithA,BartonP.Effectivenessandsafetyofnicotinereplacementtherapyassistedreductiontostopsmoking:systematicreviewandmeta-analysis.Bmj2009;338:b1024
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Thelogicofthis
• Abouthalfofsmokerstrytocutdowneveryyear.• Someseeitasapreludetoquittingwhileinothercasesthereisnofirm
plantoquit.• CuttingdownwithoutNRTleadstocompensatorysmoking.
SLIDE23
SLIDE24
SLIDE25
ContinuingNRTafteralapse
1. MostpeoplestopusingNRTwhentheylapse.2. However,warninglabelsadviseagainstusingNRTandsmoking.3. HowevercontinuingtouseNRTpatchmightreducetheprogressionto
relapse – E.g.astudyofusingpatchshoweda5-foldreductionintheriskof
fullrelapseinthosewhohadlapsed
ShiffmanS,ScharfDM,ShadelWG,GwaltneyCJ,DangQ,PatonSM,etal.Analyzingmilestonesinsmokingcessation:illustrationinanicotinepatchtrialinadultsmokers.JConsultClinPsychol2006;74(2):276-85
Longer-termuseofNRT
• SomepeoplerequireNRTforlongerthan12weeks.• <10%ofpatientsonoralNRTand<15%onnasalsprayuseNRTfora1
year.• Thechancesoflong-termusearerelatedtospeedofnicotineabsorption.• Long-termusersaremostlysmokerswhosechanceofsuccesswouldbe
otherwisesmall
HajekP,McRobbieH,GillisonF(2007)PreventiveMedicine,44,230-234
Individualizedtreatment
• Therehastraditionallybeena‘onesizefitsall’approachwithdosingofNRT.
• Thereisverylittleindividualisationoftreatmentfortobaccodependenceasthereisinthemanagementofotherchronicdiseases.
• Specialpopulations(adolescents,pregnantandbreastfeedingmothers,mentalhealthpatients-drugsmokinginteractions,etc.)
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26PAHs&DrugMetabolism
• Polycyclicaromatichydrocarbons(PAHs)intobaccosmokepotentinducersofhepaticcytochromeP-450(CYP)isoenzymes.
• ThreeinducibleCYP1familygenes(A1,A2andB1).• HepaticCYP1A2isfunctionallymostimportantCYP1genedueto
exclusive(?)liverexpression.• Drugs(substrates)oftheisoenzyme(s)mayhaveincreasemetabolism
(increaseclearance,reducehalf-life)insmokers,andtheoppositeeffectsmaybeseenpost-cessation.
• CYP1A2ismainenzymeformetabolismofclozapine,olanzapine,fluvoxamine,haloperidol.Alsoaffectsnaratiptan(antimigraineagent),andramelton(hypnotic).
SLIDE
27MainQuestion
• HowquicklydoestheinductionofCYP1A2dissipateuponsmokingcessation?
• In12subjectssmoked≥20cigs/d(range22.3–27.7cigs):Daypostquit RRinCYP1A2activity
1 12.3%
2 20.1%
3 25.0%
4 28.2%
7(steadystate) 36.1%
• Half-life(t1/2)ofCYP1A2activityaftersmokingcessation=38.6hours(Faber&Fuhr, 2004)
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SLIDE28
Varenicline:AHighlySelective∝4β2ReceptorPartialAgonist
Bindingofnicotineatthe∝4β2nicotinicreceptorintheVTAisbelievedtocausereleaseofdopamineatthenAcc
Vareniclineisa∝4β2nicotinicreceptorpartialagonist,acompoundwithdualagonistandantagonistactivities.This isbelievedtoresult inbothalesseramountofdopaminereleasefromtheVTAatthenAccaswellasthepreventionofnicotinebindingatthe∝4β2receptors.
Czech Republic. 2. Picciotto MR et al. Nicotine Tob Res. 1999; Suppl2:S121-S125.
SuitablepatientforvareniclineCommencetreatmentasprescribedhowever
DonotpickaquitdateIfafter10-12days
Patienthasspontaneously:
• Reducedurgestosmoke
• Quitsmokingcigarettes• Reducedexpiredco↓• ContinueFullCourseAsPrescribed
• RevueFortnightlyThenMonthly
Patienthas:• reducedurgestosmoke• reducedcigaretteintake• reducedexpiredCO• butnotquit ↓
Revuein10days ↓
ifasabove,ADDNRTforurgestsmoke(4mggum,4mglozengesorinhaler) ↓
ifquitcontinueasaboveuntillcompletionofcourse ↓
• ifnotquitincreasefrequencyofNRT
• oradd21mgpatch• revueforthnightlythenmonthly
• patienthas• -noreduceurgestosmoke
• -notreducedcigaretteintake
• noreductioninexpiredCO ↓
• revuein10days ↓
• ifasabovediscontinuevarenicline
Basedon:Bittounetal,COnotcigarettes/dayasindicatorofvarenicilinesuccessBangkokSRNT2008Bittounetal,combinationvarencilineandNRTDublinSRNT2009
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SLIDE29
SLIDE30
SLIDE31
Efficacy:COCHRANEREVIEWNicotinereceptorpartialagonistsforsmokingcessationEditorialgroup:CochraneTobaccoAddictionGroup.Issue2,2011.
• 11trials,6892ofwhomusedvarenicline.• Vareniclineatstandarddoseincreasedthechancesofsuccessful
long-termsmokingcessationbetween2and3xcomparedwithpharmacologicallyunassistedquitattempts.
• ThemainADRofvareniclineisnausea,butmostlyatmildtomoderatelevelsandtendingtosubsideovertime.
• Possiblelinkswithseriousadverseevents,includingdepressedmood,agitationandsuicidalthoughts,andrecently?CVADRs
AdverseEffects(AEs)
1. Duringclinicaltrials,approximately4000individualswereexposedtovarenicline
2. MostfrequentlyreportedAEs(≥10%)associatedwithvarenicline1mgvsplacebowere:
•Nausea •Abnormaldreams •Insomnia •Headache
Smokingcessationandthepsyche(labeling)
• Depressivesymptomsandonrareoccasions–suicidalideationshavebeenreported.
• Smokingcessation,withorwithouttreatment,isassociatedwithnicotinewithdrawalsymptomsandhasalsobeenassociatedwiththeexacerbationofunderlyingpsychiatricillness.
• Healthcareprovidersshouldbeawareofthepossibleemergenceofsuchbehavioralchangesinpersonsattemptingsmokingcessationandrefer/advisepatientsappropriately.
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SLIDE32
SLIDE33
ADRRELATEDTOVARENICLINE(MADRAC,2008-OCT2010)
ADVERSEEVENTS NO.OFEVENT(N=187) %
Nausea 25 13.37
Giddiness 16 8.56
Dizziness 12 6.42
AbnormalDreams 12 6.42
Insomnia 7 3.74
SuicidalAttempt 1 0.53
CVAdverseEvent No.ofEvents
1 Chestpain 3
2 Palpitation 1
3 Tachycardia 1
4 Supraventiculartachycardia 1
Since 2008, National Centre of ADR Monitoring received 122 reportsrelatedtovarenicline,ofwhich6reportswereCV-related.AllreportswereassignedcausalityC3(possible).
SLIDE34
Cost-EffectivenessofTobaccoDependence
ThetobaccodependencetreatmentsshowntobeeffectiveinUSGuideline(bothcounselingandmedication)arehighlycost-effectiverelativetootherreimbursedtreatmentsandshouldbeprovidedtoallsmokers.(StrengthofEvidence=A)
U.S.DepartmentofhealthandhumanservicesPublicHealthServiceMay2008
• Cost per life-year saved of tobacco dependence treatment has beenestimated at USD3, 539 which compares favorably to hypertensionscreeningformenages45to54($5,200)andannualcervicalscreeningforwomenages34to39($4,100).
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• Treatingtobaccodependencealsoisimportanteconomicallyinthatitcanpreventthedevelopmentofavarietyofcostlychronicdiseases,includingCV,cancer,andpulmonarydisease.
• Tobaccodependencetreatmenthasbeenreferredtoasthe“goldstandard”ofhealthcarecost-effectiveness
SLIDE
35CONCLUSIONS
Greaterutilizationofevidence-basedpharmacologicinterventionintobaccocessationeffortswillhavegreaterimpactonsmokingrates,preventionoftobaccorelateddiseases,andoverallimprovementinpublichealth
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