Smoking cessation

April 12, 2023April 12, 2023 Moustapha MounibMoustapha Mounib 11

Smoking CessationSmoking Cessation

Moustapha MounibMoustapha Mounib

Consultant Chest DiseasesConsultant Chest Diseases

Military Medical AcademyMilitary Medical Academy


Despite the reality that smoking remains the most important Despite the reality that smoking remains the most important preventable cause of death and disability, most clinicians preventable cause of death and disability, most clinicians underperform in helping smokers quit. Of the 46 million current underperform in helping smokers quit. Of the 46 million current smokers in the United States, 70% say they would like to quit, smokers in the United States, 70% say they would like to quit, but only a small fraction are able to do so on their own because but only a small fraction are able to do so on their own because nicotine is so highly additive. One third to one half of all smokers nicotine is so highly additive. One third to one half of all smokers die prematurely.die prematurely.


Reasons clinicians avoid helping smokers quit include Reasons clinicians avoid helping smokers quit include time constraints, lack of expertise, lack of financial time constraints, lack of expertise, lack of financial incentives, respect for a smoker’s privacy, fear that a incentives, respect for a smoker’s privacy, fear that a negative message might lose customers, pessimism negative message might lose customers, pessimism because most smokers are unable to quit, stigma, and because most smokers are unable to quit, stigma, and clinicians being smokers.clinicians being smokers.


THE BURDEN OF SMOKINGTHE BURDEN OF SMOKING

Tobacco use remains the Tobacco use remains the single most preventable cause single most preventable cause of death, causing about 440 of death, causing about 440 000 deaths per year in the 000 deaths per year in the United States and almost 5 United States and almost 5 million worldwide. More than million worldwide. More than 8.6 million people in the United 8.6 million people in the United States are disabled from States are disabled from smoking-related diseases, such smoking-related diseases, such as chronic obstructive as chronic obstructive pulmonary disease and lung pulmonary disease and lung cancer.cancer.


Smoking causes more than twice as many deaths Smoking causes more than twice as many deaths as human immunodeficiency virus and AIDS, alcohol as human immunodeficiency virus and AIDS, alcohol abuse, motor vehicle collisions, illicit drug use, and abuse, motor vehicle collisions, illicit drug use, and suicide combined. It causes at least 100 000 more suicide combined. It causes at least 100 000 more deaths annually than obesity. On average, smokers deaths annually than obesity. On average, smokers die 10 years earlier than nonsmokers.die 10 years earlier than nonsmokers.


Among smoking-related deaths, about 33% are from Among smoking-related deaths, about 33% are from cardiovascular diseases, 28% from lung cancer, 22% from cardiovascular diseases, 28% from lung cancer, 22% from respiratory causes, and at least 7% from cancers other than respiratory causes, and at least 7% from cancers other than lung cancer. A disproportionate number of deaths from lung cancer. A disproportionate number of deaths from smoking, probably more than 40%, occur among patients smoking, probably more than 40%, occur among patients mental illness and substance abuse disorders.mental illness and substance abuse disorders.


Nine per-cent of deaths Nine per-cent of deaths attributable to smoking occur attributable to smoking occur in nonsmokers, caused by in nonsmokers, caused by exposure to secondhand exposure to secondhand smoke, most from smoke, most from cardiovascular causes. In cardiovascular causes. In addition, smoking is a risk addition, smoking is a risk factor for an expanding list of factor for an expanding list of other illnesses; reduced other illnesses; reduced fertility in women, poor fertility in women, poor pregnancy outcomes, breast pregnancy outcomes, breast cancer, cataracts, macular cancer, cataracts, macular degeneration, and others.degeneration, and others.


BENEFITS OF QUITTINGBENEFITS OF QUITTING


Patients of any age can benefit quitting. Early Patients of any age can benefit quitting. Early improvements that occur a few weeks include better improvements that occur a few weeks include better pulmonary function and exercise tolerance. pulmonary function and exercise tolerance. Respiratory symptoms also decrease, though Respiratory symptoms also decrease, though excretion of excess mucus and tobacco residue may excretion of excess mucus and tobacco residue may cause a transient increase in coughing.cause a transient increase in coughing.


One year after cessation, the risk of coronary One year after cessation, the risk of coronary disease drops to half that of smokers, and by about disease drops to half that of smokers, and by about 15 years later, it has fallen to the rate of never 15 years later, it has fallen to the rate of never smokers. The all-cause death rate declines within smokers. The all-cause death rate declines within the first 2 years of cessation. The risk of stroke the first 2 years of cessation. The risk of stroke declines at a comparable rate.declines at a comparable rate.


Although the risk of pulmonary and other cancers Although the risk of pulmonary and other cancers never declines to the rate of nonsmokers, it falls by never declines to the rate of nonsmokers, it falls by 50% after a decade of abstention. Even smokers who 50% after a decade of abstention. Even smokers who quit at age 65 years can anticipate 4 additional years quit at age 65 years can anticipate 4 additional years of life than their counterparts who are unable to quit. In of life than their counterparts who are unable to quit. In addition to extra years of life, quality of life is another addition to extra years of life, quality of life is another important benefit of cessation.important benefit of cessation.


Addiction and nicotine pharmacologyAddiction and nicotine pharmacology


Why is it so difficult to quit smokingWhy is it so difficult to quit smoking? The physiologic actions ? The physiologic actions of nicotine are numerous and include of nicotine are numerous and include central nervous systemcentral nervous system effectseffects (pleasure, arousal, improved task performance, and (pleasure, arousal, improved task performance, and anxiety relief), anxiety relief), cardiovascular effectscardiovascular effects (increased heart rate, (increased heart rate, cardiac output, and blood pressure, as well as coronary and cardiac output, and blood pressure, as well as coronary and cutaneous vasoconstriction), cutaneous vasoconstriction), appetite suppressionappetite suppression, and , and increased metabolic rateincreased metabolic rate..


Distribution in the body is rapid: nicotine can reach Distribution in the body is rapid: nicotine can reach the brain within 11 seconds after inhaling cigarette the brain within 11 seconds after inhaling cigarette smoke. Nicotine triggers the release of multiple smoke. Nicotine triggers the release of multiple neurotransmitters, most critically dopamine. neurotransmitters, most critically dopamine. Nicotine absorption is pH-dependent; at Nicotine absorption is pH-dependent; at physiologic pH levels, it is well absorbed, but in physiologic pH levels, it is well absorbed, but in more acidic media, absorption is inhibited.more acidic media, absorption is inhibited.


Most nicotine is metabolized in the liver, and the Most nicotine is metabolized in the liver, and the major metabolite, cotinine, is excreted in the major metabolite, cotinine, is excreted in the urine. Long-term exposure to nicotine results in urine. Long-term exposure to nicotine results in up-regulation of nicotine receptors in the nucleus up-regulation of nicotine receptors in the nucleus accumbens and ventral segmental areas of the accumbens and ventral segmental areas of the midbrain.midbrain.


Tolerance develops after long-term nicotine use, Tolerance develops after long-term nicotine use, but in smokers sensitivity is restored overnight-but in smokers sensitivity is restored overnight-hence, the appeal of the first morning cigarette, hence, the appeal of the first morning cigarette, which serves to restore nicotine levels in the which serves to restore nicotine levels in the brain. Smokers can self-regulate nicotine intake brain. Smokers can self-regulate nicotine intake by the frequency of cigarette consumption, the by the frequency of cigarette consumption, the intensity of inhalation, and the degree to which intensity of inhalation, and the degree to which vents and other filtering devices on cigarettes vents and other filtering devices on cigarettes are manually obstructed. To maintain a given are manually obstructed. To maintain a given nicotine level, smokers generally titrate their nicotine level, smokers generally titrate their smoking to achieve maximal stimulation and smoking to achieve maximal stimulation and avoid withdrawal symptoms.avoid withdrawal symptoms.


The symptoms of nicotine withdrawal are profound: The symptoms of nicotine withdrawal are profound: anger and irritability, anxiety, cravings, decreased anger and irritability, anxiety, cravings, decreased concentration, hunger and weight gain, concentration, hunger and weight gain, restlessness, drowsiness, fatigue, impaired task restlessness, drowsiness, fatigue, impaired task performance, and sleep disturbance. Assessing the performance, and sleep disturbance. Assessing the extent of addiction helps in planning an appropriate extent of addiction helps in planning an appropriate treatment strategy and monitoring progress.treatment strategy and monitoring progress.


Smoking cessation interventionsSmoking cessation interventions


There are 5 basic ways to help smoking quitThere are 5 basic ways to help smoking quit: : increase the price of a pack of cigarettes by increase the price of a pack of cigarettes by increasing taxes; pass clean indoor air legislation increasing taxes; pass clean indoor air legislation that bans smoking in public places; create and that bans smoking in public places; create and disseminate effective counter-marketing messages disseminate effective counter-marketing messages about smoking-in the media or as graphic package about smoking-in the media or as graphic package displays; ban tobacco advertising and promotion; displays; ban tobacco advertising and promotion; and provide cessation aids.and provide cessation aids.


Religious point of viewReligious point of view


The gold standard for initiating smoking cessation The gold standard for initiating smoking cessation treatment is the 5 As: treatment is the 5 As:

Asking Asking about tobacco use,about tobacco use,

AdvisingAdvising tobacco users to quit, tobacco users to quit,

AssessingAssessing readiness to make a quit attempt, readiness to make a quit attempt,

AssistingAssisting with the quit attempt, with the quit attempt,

ArrangingArranging follow-up care. follow-up care.


What are the four R’s of motivational What are the four R’s of motivational interventionsinterventions


1-1-RelevanceRelevance; information should be provided that is ; information should be provided that is relevant to the patient’s sociodemographic relevant to the patient’s sociodemographic characteristics, disease status, health concerns, and characteristics, disease status, health concerns, and social situation.social situation.

2-2-RisksRisks; acute, long term, and environmental risks ; acute, long term, and environmental risks should be discussed with the patient.should be discussed with the patient.

33--RewardsRewards; the clinician should highlight potential ; the clinician should highlight potential rewards of stopping that seem relevant to the rewards of stopping that seem relevant to the patient.patient.

4-4-RepetitionRepetition; the motivational intervention should be ; the motivational intervention should be repeated every time an unmotivated smoker visit the repeated every time an unmotivated smoker visit the clinic.clinic.


Cessation OptionsCessation Options


Cessation Options;Cessation Options;

* * Counseling.Counseling.

* * Pharmacotherapy.Pharmacotherapy.


The odds of a smoker quitting are increased both The odds of a smoker quitting are increased both by counseling and by pharmacological by counseling and by pharmacological treatment. Cognitive therapy aims to reframe the treatment. Cognitive therapy aims to reframe the way a patient thinks about smoking. Smokers way a patient thinks about smoking. Smokers are taught techniques of distraction, positivism, are taught techniques of distraction, positivism, relaxation, and mental imagery and are offered relaxation, and mental imagery and are offered encouragement and motivation. encouragement and motivation.


In contrast, behavioral therapy helps smokers In contrast, behavioral therapy helps smokers avoid stimuli that trigger smoking, such as alcohol, avoid stimuli that trigger smoking, such as alcohol, first morning coffee, stress, and associating with first morning coffee, stress, and associating with other smokers. Behavioral strategies also attempt other smokers. Behavioral strategies also attempt to alter the usual smoking routine, anticipate to alter the usual smoking routine, anticipate cravings, and address the consequences of cravings, and address the consequences of nicotine withdrawal, such as oral needs, weight nicotine withdrawal, such as oral needs, weight gain, and cravings. Intensive counseling is gain, and cravings. Intensive counseling is associated with a 22% rate of quitting, and even associated with a 22% rate of quitting, and even minimal (<3 minutes) counseling is associated with minimal (<3 minutes) counseling is associated with a 13% quit rate.a 13% quit rate.


PharmacotherapyPharmacotherapy

Two general classes of drugs are approved by Two general classes of drugs are approved by FDA for cessation:FDA for cessation:

1-Nicotine replacements products (NRTs)1-Nicotine replacements products (NRTs)

2-Psychotropic drugs.2-Psychotropic drugs.


Available Forms of Nicotine Replacement TherapyAvailable Forms of Nicotine Replacement Therapy

1-1-GumGum;;

2 mg and 4 mg doses2 mg and 4 mg doses

Recommended for up to 12 weeksRecommended for up to 12 weeks

2-2-PatchPatch;;

Seven strengths 5, 7, 10, 14, 15, 21, and 22 mgSeven strengths 5, 7, 10, 14, 15, 21, and 22 mg

16 or 24 hour release16 or 24 hour release

3-3-LozengeLozenge;;

2 mg and 4 mg doses2 mg and 4 mg doses

1 lozenge to be used every 1 to 2 hours while awake1 lozenge to be used every 1 to 2 hours while awake

Recommended for up to 12 weeksRecommended for up to 12 weeks


4- 4- Nasal sprayNasal spray;;

0.5 mg per spray0.5 mg per spray

1 to 2 doses every hour1 to 2 doses every hour

Not to exceed 40 doses per dayNot to exceed 40 doses per day

Can be used for 3 to 6 monthsCan be used for 3 to 6 months

5- 5- InhalerInhaler;;

4 mg per cartridge4 mg per cartridge

1 cartridge to be used every 1 to 2 hours while awake1 cartridge to be used every 1 to 2 hours while awake

6 to 16 cartridges per day6 to 16 cartridges per day

Can be used up to 6 monthsCan be used up to 6 months


Nicotine ReplacementNicotine Replacement

The choice of an NRT product should be individualized, The choice of an NRT product should be individualized, based on patient preference, tolerance of adverse effects, based on patient preference, tolerance of adverse effects, and smoking habits. Higher doses are more likely to be and smoking habits. Higher doses are more likely to be effective but also to produce adverse effects. Increasingly; effective but also to produce adverse effects. Increasingly; patients with severe nicotine addiction are prescribed patients with severe nicotine addiction are prescribed combination NRT, a patch plus one of the short-acting combination NRT, a patch plus one of the short-acting formulations. Higher -than –recommended doses may be formulations. Higher -than –recommended doses may be indicated in smokers with severe addiction, and failure to indicated in smokers with severe addiction, and failure to respond may reflect inadequate dosage, incorrect usage, or respond may reflect inadequate dosage, incorrect usage, or both.both.


The nicotine patch The nicotine patch is emerging as a mainstay for is emerging as a mainstay for pharmacological treatment of smoking cessation, often pharmacological treatment of smoking cessation, often in combination with other forms of nicotine replacement in combination with other forms of nicotine replacement and psychotropic medications. Its major advantages and psychotropic medications. Its major advantages are consistent levels of nicotine delivery, easy use and are consistent levels of nicotine delivery, easy use and concealment, and good compliance.concealment, and good compliance.


Disadvantages include insomnia (greater with the 24 Disadvantages include insomnia (greater with the 24 -hour patch), inability to titrate dose, allergic reactions -hour patch), inability to titrate dose, allergic reactions to the patch adhesive (patients with dermatological to the patch adhesive (patients with dermatological conditions are advised against its use), and morning conditions are advised against its use), and morning nicotine cravings with the 16- hour release form.nicotine cravings with the 16- hour release form.


In general, greater levels of smoking call for In general, greater levels of smoking call for higher-dose patches, and morning cravings higher-dose patches, and morning cravings necessitate the use of the 24-hour formulation. necessitate the use of the 24-hour formulation. Patch sites should be rotated to avoid skin Patch sites should be rotated to avoid skin reactions. Most patients can tolerate the skin reactions. Most patients can tolerate the skin irritation, which topical corticosteroids can irritation, which topical corticosteroids can ameliorate.ameliorate.


Nicotine gumNicotine gum may satisfy oral cravings, may delay may satisfy oral cravings, may delay weight gain after cessation, and lends itself to titration weight gain after cessation, and lends itself to titration for control of withdrawal symptoms. Its major for control of withdrawal symptoms. Its major disadvantages include that its use may not be socially disadvantages include that its use may not be socially acceptable, it may adhere to dental work such as acceptable, it may adhere to dental work such as fillings and bridges, and it must be used properly to fillings and bridges, and it must be used properly to be effective.be effective.


The The Nicotine lozengeNicotine lozenge, like the gum, can satisfy , like the gum, can satisfy oral cravings and also lends itself to titration of oral cravings and also lends itself to titration of nicotine delivery. It is easy to use and to nicotine delivery. It is easy to use and to conceal, and, thus, may be more socially conceal, and, thus, may be more socially acceptable than the gum. In many patients, acceptable than the gum. In many patients, the lozenge is well tolerated, but heavy users the lozenge is well tolerated, but heavy users may note adverse effects of hiccups, nausea, may note adverse effects of hiccups, nausea, dyspepsia, and flatulence.dyspepsia, and flatulence.


Using Using Nasal sprayNasal spray to deliver periodic doses of to deliver periodic doses of nicotine more closely mimics the act of smoking. Its nicotine more closely mimics the act of smoking. Its advantages include rapid absorption, ease of titrating advantages include rapid absorption, ease of titrating doses to attain desired nicotine levels, and similarity doses to attain desired nicotine levels, and similarity to the act of smoking. Disadvantages include a high to the act of smoking. Disadvantages include a high rate of nasal and throat irritation (generally tolerated rate of nasal and throat irritation (generally tolerated by users), the risk of dependence, and the need to by users), the risk of dependence, and the need to wait up to 5 minutes before driving because of local wait up to 5 minutes before driving because of local reactions and sneezing. Patients with chronic nasal reactions and sneezing. Patients with chronic nasal disorders or reactive airway disease should not use disorders or reactive airway disease should not use the spray.the spray.


Finally, the Finally, the Nicotine inhaler,Nicotine inhaler, like the nasal spray, like the nasal spray, mimics the act of smoking and permits titration of mimics the act of smoking and permits titration of nicotine. It also can cause local irritation and nicotine. It also can cause local irritation and should be used cautiously in patients with should be used cautiously in patients with bronchospastic disease. Slow inhalation lessens bronchospastic disease. Slow inhalation lessens the chance of such irritation.the chance of such irritation.


Psychotropic MedicationsPsychotropic Medications

The only psychoactive drug currently recommended The only psychoactive drug currently recommended by the FDA for cessation is by the FDA for cessation is BupropionBupropion, , an atypical an atypical antidepressant thought to affect levels of various antidepressant thought to affect levels of various brain neurotransmitters, including dopamine and brain neurotransmitters, including dopamine and norepinephrine. Prescribed in 150-mg doses as a norepinephrine. Prescribed in 150-mg doses as a sustained-release capsule, bupropion seems to act sustained-release capsule, bupropion seems to act by decreasing both the craving for cigarettes and the by decreasing both the craving for cigarettes and the symptoms of nicotine withdrawal.symptoms of nicotine withdrawal.


Given the high prevalence of smokers who are Given the high prevalence of smokers who are depressed, bupropion has the added advantage of depressed, bupropion has the added advantage of treating both conditions simultaneously. It is easy to treating both conditions simultaneously. It is easy to use and can be taken in combination with NRT. use and can be taken in combination with NRT. Because bupropion may forestall the weight gain Because bupropion may forestall the weight gain that so commonly accompanies cessation, it is that so commonly accompanies cessation, it is particularly appropriate for smokers with weight particularly appropriate for smokers with weight concerns.concerns.


The drug should be started at least 1 week before The drug should be started at least 1 week before the cessation date to achieve stable blood levels. the cessation date to achieve stable blood levels. Initially, the patient should take 1 pill each morning Initially, the patient should take 1 pill each morning for 3 days, increasing to twice a day if tolerated for 3 days, increasing to twice a day if tolerated although once a day may suffice in some patients. although once a day may suffice in some patients. Treatment usually is recommended for 2 to 3 months Treatment usually is recommended for 2 to 3 months after the cessation date, but in selected cases it may after the cessation date, but in selected cases it may be taken for up to a year.be taken for up to a year.


Bupropion is contraindicated for patients with Bupropion is contraindicated for patients with seizure disorders or conditions that might predispose seizure disorders or conditions that might predispose to seizures (brain tumors, head trauma, other to seizures (brain tumors, head trauma, other medications that lower seizure thresholds, bulimia, medications that lower seizure thresholds, bulimia, and anorexia nervosa) . Adverse reactions among and anorexia nervosa) . Adverse reactions among those without risk of seizure include insomnia those without risk of seizure include insomnia (mitigated by taking the second dose in late afternoon (mitigated by taking the second dose in late afternoon rather than at bedtime) and dry mouth.rather than at bedtime) and dry mouth.


The US Public Health Service has The US Public Health Service has recommended as second-line agents for cessation recommended as second-line agents for cessation 2 centrally active medications currently used for 2 centrally active medications currently used for other conditions; other conditions; Nortriptyline,Nortriptyline, a tricyclic a tricyclic antidepressant, and antidepressant, and Clonidine,Clonidine, a centrally active a centrally active agonist. Neither is approved by the FDA for agonist. Neither is approved by the FDA for smoking cessation.smoking cessation.


For the heavily addicted smoker, triple therapy is For the heavily addicted smoker, triple therapy is advocated: the nicotine patch plus a short-acting advocated: the nicotine patch plus a short-acting NRT plus bupropion. Clinicians should reserve this NRT plus bupropion. Clinicians should reserve this option for smokers who can tolerate the combined option for smokers who can tolerate the combined risk of adverse effects and who are unlikely to quit risk of adverse effects and who are unlikely to quit with a simpler regimen.with a simpler regimen.


Future Medication OptionsFuture Medication Options

Several potential new medications for cessation are Several potential new medications for cessation are currently in field tests and not yet approved by the currently in field tests and not yet approved by the FDA. FDA. RimonabantRimonabant is a cannabinoid receptor inhibitor is a cannabinoid receptor inhibitor that blocks the reinforcing effects of nicotine and also that blocks the reinforcing effects of nicotine and also suppresses appetite. Now in phase 3 trials, it has suppresses appetite. Now in phase 3 trials, it has already receive much attention for its potential to already receive much attention for its potential to attack 2 major public health epidemics; smoking and attack 2 major public health epidemics; smoking and obesity.obesity.


Nicotine vaccineNicotine vaccine produces antibodies to nicotine and produces antibodies to nicotine and thus reduces nicotine levels. Whether it will discourage thus reduces nicotine levels. Whether it will discourage smokers or stimulate more aggressive smoking to smokers or stimulate more aggressive smoking to overcome the blockade is yet unclear.overcome the blockade is yet unclear.


Another psychotropic drug, Another psychotropic drug, Varenicline,Varenicline, may offer may offer an alternative to bupropion. Finally, an alternative to bupropion. Finally, Cytochrome Cytochrome P246 inhibitorsP246 inhibitors decrease the action of the decrease the action of the cytochrome P246 liver enzyme that metabolizes cytochrome P246 liver enzyme that metabolizes nicotine, thus giving smokers a higher level of nicotine, thus giving smokers a higher level of nicotine per cigarette. These drugs could be used nicotine per cigarette. These drugs could be used to help smokers who are not ready to quit cut to help smokers who are not ready to quit cut back on their smoking levels, as well as to back on their smoking levels, as well as to increase the potency of NRT. increase the potency of NRT.

Electronic cigaretteElectronic cigarette


Electronic cigarettes ( e-cigarettes ) Electronic cigarettes ( e-cigarettes ) are marketed as potentially reduced are marketed as potentially reduced tobacco products. The product resembles, tobacco products. The product resembles, but is not, a cigarette in design or function but is not, a cigarette in design or function and is marketed as “ safer “ than a and is marketed as “ safer “ than a conventional cigarette.conventional cigarette.


Because e-cigarettes do not Because e-cigarettes do not contain or burn tobacco, they do not contain or burn tobacco, they do not appear to deliver the known toxins appear to deliver the known toxins found in conventional cigarette smoke.found in conventional cigarette smoke.


Conversely, US Food and Drug Conversely, US Food and Drug Administration (FDA ) analyses have Administration (FDA ) analyses have indicated that e-cigarettes contain a number indicated that e-cigarettes contain a number of toxins and carcinogens, including of toxins and carcinogens, including tobacco-specific nitrosamines, diethylene tobacco-specific nitrosamines, diethylene glycol, and other components suspected of glycol, and other components suspected of being harmful to humans.being harmful to humans.


The study aimed to assess whether using The study aimed to assess whether using an e-cigarette for 5 min has an impact on the an e-cigarette for 5 min has an impact on the pulmonary function tests and fraction of pulmonary function tests and fraction of exhaled nitric oxide ( Fexhaled nitric oxide ( FENO )ENO ) of healthy adult of healthy adult smoker.smoker.

Using an e-cigarette for 5 min led to an Using an e-cigarette for 5 min led to an immediate decrease in Fimmediate decrease in FENO, ENO, and an increase and an increase in of total respiratory impedance at 5 Hz, in of total respiratory impedance at 5 Hz, increase in flow respiratory resistance at 5Hz, increase in flow respiratory resistance at 5Hz, 10 Hz and 20 Hz.10 Hz and 20 Hz.


E-cigarettes were found to have immediate E-cigarettes were found to have immediate adverse physiologic effects after short time adverse physiologic effects after short time use that are similar to some of the effects use that are similar to some of the effects seen with tobacco smoking ; however, the seen with tobacco smoking ; however, the long term health effects of e-cigarette use are long term health effects of e-cigarette use are unknown but potentially adverse effects are unknown but potentially adverse effects are worthy of further investigation.worthy of further investigation.

CHEST 2012 ; 141 (6) 1400-1406.CHEST 2012 ; 141 (6) 1400-1406.


MPOWERMPOWER MM onitor tobacco use. onitor tobacco use. PP rotect people from tobacco rotect people from tobacco

use.use. OO ffer help to quit tobacco ffer help to quit tobacco

use.use. WW arn about the damages of arn about the damages of

tobacco .tobacco . EE nforce bans on tobacco nforce bans on tobacco

advertising, promotion and advertising, promotion and sponsorship.sponsorship.

RR aise taxes on tobacco aise taxes on tobacco products,products,



Thank youThank you

Smoking cessation

Documents

Transcript of Smoking cessation