1. Helping your patients
quit smoking

2. • Is smoking that dangerous
• Quitting: research to practice
• Neurobiology of smoking
• What to target – prevention or
quitting

3. • Is smoking that dangerous
• Quitting: research to practice
• Neurobiology of smoking
• What to target – prevention or
quitting

5. INTERHEART: Smoking
and MI
16
8
OR (99% CI)
4
2
1
Never 1-5 6-10 11-15 16-20 21-25 26-30
Cont 31-40 7489
41+ 727 1031 446 1058 96 230
168 56
Cases 4223 469 1021 623 1832 254 538 459

6. INTERHEART: Clinical implications
• 9 simple and modifiable risk factors are strongly
associated with acute MI worldwide.
• These 9 risk factors account for >90% of the PAR
globally and in most regions.
• Abnormal ApoB-ApoA1 ratio and smoking are the 2
most important risk factors and account for over
two thirds of the PAR.
• Implementing preventive strategies based on our
current knowledge would prevent the majority of
premature CHD worldwide.
PAR = population attributable risk
Apo = apolipoprotein Yusuf S et al. Lancet. 2004;364:937-52.

8. Tobacco products are
responsible for three
million (30 lakh)
deaths annually world
wide or about 6% of
all deaths

9. • Is smoking that dangerous
• Quitting: research to practice
• Neurobiology of smoking
• What to target – prevention or
quitting

10. Overall risk to smokers and never-
smokers
100 Never smoked
regularly
80
80
Current cigarette
smokers 59
% Alive
60
7.5 years
40 33
20 12
0
40 55 70 85 100
Age
Doll et al BMJ

11. Effects on survival after ages 45, 55, 65 & 75
of stopping smoking in previous decade
100 100
80 80
nonsmokers
% Alive
% Alive
60 60
40 40 Former smokers
Former smokers
20 stopped 35-44 20 stopped 45-54
smokers
0 0
40 55 70 85 100 40 55 70 85 100
Age Age
100 100
80 80
% Alive
% Alive
60 60
40 40
Former smokers Former smokers
20 stopped 55-64 20 stopped 65+
0 0
40 55 70 85 100 40 55 70 85 100
Age Age
Doll et al BMJ

12. • Is smoking that dangerous
• Quitting: research to practice
• Neurobiology of smoking
• What to target – prevention or
quitting

14. the first exposure
to nicotine can
create an
enduring ‘memory
trace,’ which
instills the desire
to repeat the
experience and
amplifies the
pleasing effects of
subsequent
nicotine exposure

15. Molecular and Behavioral Aspects of Nicotine Addiction
Benowitz N. N Engl J Med 2010;362:2295-2303

18. International journal of Biochemistry and cell biology 41 (2009)

22. Continuous Abstinence Rates The Ns shown in the key are the denominators used for all 3
periods.
Gonzales, D. et al. JAMA 2006;296:47-55
Copyright restrictions may apply.

23. Varenicline as Compared with Placebo
Hays J, Ebbert J. N Engl J Med 2008;359:2018-2024

24. • Is smoking that dangerous
• Quitting: research to practice
• Neurobiology of smoking
• What to target – prevention or
quitting

25. Scenarios for future deaths from
tobacco
Cumulative deaths from tobacco (millions)
520
500
Trend
400
300
220
200
100 70
0
1950 1975 2000 2025 2050
Year
Source: Peto et al

26. Cumulative deaths from tobacco (millions)
Scenarios: impact of prevention
520
500 500
Trend
If smoking
uptake halves
400
by 2020
300
220
200
100 70
0
1950 1975 2000 2025 2050
Year
Source: Peto et al

27. Cumulative deaths from tobacco (millions) Scenarios: impact of cessation
520
500 500
Trend
If smoking
uptake halves
400
by 2020
300 340
220 If adult smoking
200 halves by 2020
190
100 70
0
1950 1975 2000 2025 2050
Year
Source: Peto et al

28. • Any organ that
is spared?

29. Slama et all,1995

30. 1. JAMA2006 ; 296 : 47-55
2. Thorax 2000 ; 55: 987-99

32.  Ask
 Advice
 Assess
 Assist
 Arrange follow up

33. ASK
• Action : every patient at every
clinical visit, status of tobacco use
queried and documented

34. • Vital signs
• Mark with a sticker or
• Colouring in the book

35.  Ask
 Advice
 Assess
 Assist
 Arrange follow up

36. ADVISE
• ACTION: Clear, Strong and
personalized manner

37. CLEAR
- It is important that you quit
smoking now and I can help you
- Cutting down while you are ill is
not enough
- Occasional or light smoking is still
dangerous

38. STRONG
As your doctor I feel that quitting
smoking is the best thing you can
do to protect your health. If you
are willing we are here to help you
out

39. • PERSONALISED
Continuing smoking worsens your
asthma/increases your child ear
infection/you will also get stroke
like your father

40. Frequency of physicians advising
patients to quit smoking:
21% of the time
Thorndike in 1995

41.  Ask
 Advice
 Assess
 Assist
 Arrange follow up

42. ASSESS
• Whether he is willing to quit
smoking,
• How much is he dependant on
smoking

43. How much is he dependant on
NICOTINE

45.  Ask
 Advice
 Assess
 Assist
 Arrange follow up

46. Why he wants to QUIT ?
 “I will feel healthier right way. More energy,
better sense of smell, taste, breathe & focus
 I will be healthier the rest of my life. I will
lower my risk for cancer, heart attacks,
strokes, earthly death, cataracts & wrinkling.
 I will make my wife, kids& friends proud of me
 I will no longer expose others to my smoke
 I will have more money to spend.
 I will be proud of myself.
 I won’t have worry:when & where I will smoke
next”

48. Keep track of when & why he
smokes
• “Keep a record of every cigarette you
smoke.
• Do this for the next few weeks
• You will know why and when you
smoke
• You will learn more about your triggers.
• These will help you prepare to fight
your urge to smoke”

49. Addressing cues

50. Psychological obstacles to
quitting

51. 1. Fear of Failure
Very common obstacle
-no one want to fail
Quitting can be a very public event
-prospect become even more
scary
Quitting a process of change
no one can quit - unless he really
wants to

52. 2.Concerns about loss of
productivity
• Nonsmokers tend to perform
better than smokers ,both with
and without cigarettes in a task
that required concentration.
• Smokers who were not allowed to
smoke may be thinking about
cigarettes, which may distract
them

53. 3.Concerns about Stress
• Nicotine is helpful in improving
mood and decreasing negative
feelings during stressful times.
• If he smokes for stress reduction,
he must make the decision that he
will find other ways to cope.

54. 4.Concerns about Nicotine
Withdrawal
• The more he exposes his body to
nicotine, the more his body needs
it and the less it responds to it.
• NWS will cause lots of
unpleasantness.

55. Nicotine Withdrawal Syndrome.
• Daily use of nicotine for at least several weeks
• Abrupt cessation or reduction of nicotine
followed within twenty four hours by at least
four of the following symptoms
-craving for nicotine
-irritability ,frustration or anger
-anxiety
-difficulty concentrating
-restlessness
-decreased heart rate
-increased appetite or weight gain

56. • Nicotine Withdrawal Syndrome is experienced
by one in four heavy smokers and most light
smokers experienced no symptoms at all.
• NWS peak in intensity during the first twenty
four to forty eight hours after he stops using
nicotine.

57. 5.Concerns about his Age
• People over sixty-five who were
thinking about quitting, two-thirds
were not confident that they could
succeed
• Almost half of the smokers over
sixty- five reported that they did
not believe quitting would provide
them with health benefits, and an
almost equal number did not
believe that continuing smoking

58. 6.Concerns about weight
gain
• Eight in ten who quit will gain
weight over a period of two years
• The average weight gain as a
result of quitting can be four
pounds more than would be
expected if you continued smoking

59. • But why people gain weight
the reason being people
smoke instead of eating

60. • Attention to his diet and exercising
can counteract any tendency to
gain weight.

61. Common excuses 1
• My X lived till he was 85 and he
smoked

62. Common excuses 2
• All the damage is already done

63. Within twenty minutes of last
cigarette
• blood pressure - normal
• pulse to normal rate
• body temperature of peripheries
-increases

64. Within eight hours
• CO in blood drops to normal
• O2 in blood increases to normal

65. Within forty-eight hours
• nerve ending start re-growing
• abilities to smell and taste things
-enhanced

66. Within seventy- two hours
• The bronchial tube relax, making
breathing easier.

67. Within two weeks to three
months
• circulation improves
• walking becomes easier
• LFT increases by up to 30 percent

68. With in a year
• coughing
• fatigue improves

69. Long term benefits
1 year - CHD
5 years - stroke
10 years - lung Ca
15 years - risk of death

70. Common excuses 3
• A lot of doctors still smoke

71. Common excuses 4
• What about air pollution

72. Common excuses 5
• I’ve switched to a filter cigarette

73. Quit plan

78. INSOMNIA
CONCENTRATE
RELAXATION
COUGHING
DEPRESSION
CRAVING
CONTROLING
THOUGHTS
STRESS

79. enjoying meals
around smokers
drinking coffee or tea
having a drink •
• facing boredom
facing the morning •
• insomnia
talking on telephone •
traveling by car
watching TV
Bowel movement

80.  Ask
 Advice
 Assess
 Assist
 Arrange follow up

81. Unmotivated patients

82. Unmotivated patients
• Relevance
• Risks
• Rewards
• Roadblocks
• Repetition

83. • Relevance • Encourage the patient
• Risks to identify why
quitting is personally
• Rewards
relevant
• Roadblocks
• Repetition

84. • Relevance • Acute
• Risks • Long term
• Rewards • Environmental
• Roadblocks
• Repetition

85. • Relevance • Improved health
• Improved sense of smell
• Risks • Save money
•
• Rewards •
Feel better about yourself
Home, car, clothing, and breath
• Roadblocks will smell better
• Can stop worrying about quitting
• Repetition • Set a good example for children
• Have healthier babies and
children
• Eliminate children exposure to
smoke
• Feel better physically
• Perform better in physical
activities
• Reduced wrinkling/aging of skin

86. • Relevance
• Risks • Withdrawal symptoms
• Fear of failure
• Rewards
• Weight gain
• Roadblocks • Lack of support
• Repetition • Depression
• Enjoyment of tobacco
• Partner or room mate
smokes

87. • Relevance
• Risks • Repeat the
• Rewards motivational
• Roadblocks intervention every
time the unmotivated
• Repetition patient visits the
clinic.

90. All patients should be asked
if they use tobacco and
should have their tobacco
use status documented on a
regular basis. Evidence has
shown that clinic screening
systems, such as expanding
the vital signs to include
tobacco use status or the use
of other reminder systems
such as chart stickers
significantly increase rates of
clinician intervention

91. Tobacco
dependence
treatment is
effective and
should be
delivered even if
specialized
assessments are
not used or
available

92. All physicians should
strongly advise every
patient who smokes to
quit because evidence
shows that physician
advice to quit smoking
increases abstinence
rates.
The time for intervention is
3-5 mins.

93. The combination of
counseling and medication
is more effective for
smoking cessation than
either medication or
counseling alone.
Therefore, whenever
feasible and appropriate,
both counseling and
medication should be
provided to patients trying
to quit smoking.

94. Bupropion SR Nicotine
gum are effective
smoking cessation
treatment that
patients should be
encouraged to use.

95. Clinicians should
encourage all patients
attempting to quit to
use effective
medications for
tobacco dependence
treatment, except
where contraindicated
or for specific
populations for which
there is insufficient
evidence of
effectiveness

98. TOGETHER WE CAN ACCOMPLISH
GREAT THINGS

100. THANK YOU
FOR YOUR
PATIENT
LISTENING
majorgowri@gmail.com