methods of tobacco cessation.

1. METHODS OF TOBACCO
CESSATION

2. CONTENTS
 1.INTRODUCTION
 2.HISTORY OF TOBACCO
USE
 3.TOBACCO ADDICTION
“YOUNG SMOKERS”
 4.WHY TOBACCO
CESSATION?
 5.BARRIERS OF TOBACCO
CESSATION
INTERVENTIONS

3.  6.GOALS AND GUIDELINES OF
CESSATION PROGRAMMES
 7.BEHAVIORAL MANAGEMENT
 8.PHARMACOTHERAPIES
 9.COUSELLING FOR THOSE
UNWILLING TO QUIT
 10.CONCLUSION
 11..REFERENCES

4. INTRODUCTION:
 Tobacco use is described as the single most
important preventable cause of mortality and
morbidity globally.
 It has been considered one of the strangest
human behaviors , which is necessary neither for
the maintenance of life nor for the satisfaction of
social , cultural or spiritual needs.
 Inspite of the known association of major diseases
with tobacco,its continued use is an important
PUBLIC HEALTH ISSUE.

5. A BRIEF ACCOUNT OF TOBACCO RELATED
FACTS:
Plant product
obtained from
genus
NICOTIANA
plants belonging
to potatoe
family.
Carries in its
leaves an
alkaloid
NICOTINE

6. HISTORY OF TOBACCO
 Accounts back to 500 yrs.
 In 1492,after tobacco was
introduced to
CHRISTOPHER
COLUMBUS by native
Americans , when he
discovered AMERICA

7. INDIAN SCENARIO:
 Introduced by
Portuguese traders in
about 1600 A.D.
 Offered to emperor
Akbar.
 Hookah was invented.
 Addiction spread like
wildfire.
 Soon it became a
symbol of aristocracy.

8. ALARMING FACTS ABOUT TOBACCO USE:
 GLOBAL PICTURE:
 Tobacco kills nearly 6
million people world wide.
 According to WHO,
100 million premature deaths
were attributed to tobacco
use in 20th century.
If current trend continues ,no
.is expected to rise to 1 billion
in 21st century.

9.  Estimates of the Global Adult
Tobacco Survey conducted
among persons of 15 yrs or
older during 2009-2010
indicate:
 34.6% Of The Adults(47.9% Are
Males And 20.3% Females) Are
Current Tobacco Smokers.
 14% Adults Smoke(24.3% Males
And 2.9% Females)
 25.9% use smokeless
tobacco(32.9%males and 18.4%
females)
GLOBAL ADULT TOBACCO
SURVEY (GATS) INDIA:2009-2010
AVAILABLE
FROM:http://www.searo.who.int
INDIAN SCENARIO

10. VARIOUS FORMS OF TOBACCO USED IN INDIA:
SMOKELESS TOBACCO
PAN WITH TOBACCO
GUTKHA
MANIPURI TOBACCO
MAWA
KHAINI
MISHRI
SNUFF
ZARDA

11. SMOKED TOBACCO
BEEDI
CHILLUM
CHULTA
CIGARETTE
DHUMTI
HOOKAH
HOOKLI
NASWAR

12.  CIGARETTE SMOKING is the most common both in
terms of prevalence and health consequences.

13. IN INDIAN CONTEXT ,BEEDI SMOKING IS MORE
COMMON BECAUSE OF ECONOMIC REASONS.

14. TOBACCO ADDICTION:
 NICOTINE
(principle
ingredient)
 Responsible for
addiction.
 Euphoric effect
leads to tobacco
addiction.

15.  It is known to
activate the
dopamine reward
system of the body
leading to the
release of
dopamine and
endorphins i.e
associated with the
feeling of pleasure

16. STARTING TO SMOKE: IT IS MAINLY INITIATED
BY FOLLOWING FACTORS.
 Environmental
 Parental smoking
 Deprieved backgrounds.

17.  Smoking by siblings
& friends ,peer groups

18. ADVERTISING AND PROMOTIONS TARGETING
YOUNG PEOPLE:

19. BEHAVIORAL :
 Linked to poor
school performance.
 Associated with other
abuse habits like
alcohol
and drug misuse.

20. PERSONAL
 Low self esteem

21.  Low knowledge of adverse
effects.
 Anxiety
 Out of curiosity.

22. HARMFUL EFFECTS OF TOBACCO USE:

23.  Harmful effects of smokeless tobacco

24. TOBACCO CESSATION…………..WHY?
THE BENEFITS…………….
 Estimation states that if adult consumption were to
decrease by 50% by the year 2020,approx 180 million
tobacco related deaths could be avoided.
 To reduce tobacco related deaths and diseases
current smokers must quit tobacco.

25. Fact sheet about health benefits of smoking
cessation.
A)Immediate And Long Term Health Benefits Of
Quitting For All Smokers.
TIME SINCE QUITTING BENEFICIAL HEALTH CHANGES
Within 20 min Heart rate and blood pressure drops.
Within 12 hrs CO level in blood drops
2-12 weeks Circulation improves and lung function increases.
1-9 months Coughing and shortness of breath decreases.
1 year Risk of coronary heart disease is about half that
of a smoker.
5 years Stroke risk is reduced to that of a non smoker
10 years Risk of lung cancer falls to about half of a smoker
and risk of cancer of
mouth,throat,esophagus,cervix and pancreas
decreases.

26. B)People of all ages who have already developed
smoking elated health problems can still benefit from
quitting.
Time of quitting Benefits in comparison with those
who continued
At about 30 Gain almost 10 yrs of life expectancy
At about 40 Gain 9 years of life expectancy
At about 50 Gain 6 yrs of life expectancy.
At about 60 Gain 3 yrs of life expectancy.
After the onset of life
threatening disease
Rapid benefit,people who quit smoking
after having a heart attack reduce their
chances of having of having heart attack
by 50%

27. 3)Quitting smoking decreases the excess risk of
many diseases related to second hand smoke in
children,such as respiratory diseases e.g., asthma
and ear infections.
4)Quitting smoking reduces the chances of
impotence ,having difficulty getting pregnant ,
having premature births , babies with low
birthweights and miscarriage.

28. BARRIERS TO TOBACCO CESSATION
INTERVENTIONS:
1.Lack of knowledge:
Of the health effects of the tobacco use.
2.Nicotine Dependence:
Nature of nicotine dependence itself is the
single most important factor affecting smoking
cessation interventions.Even smoking a single
cigarette can cause nicotine dependence.

29. 3.Deeply ingrained cultural habits particularly in rural
areas.
4.Lack of tobacco cessation motivation,Advice and
support/Lack of Trained Health professionals:
A recent study in India reported that 83% of tobacco
users wanted to quit,of whom 51% were unsuccessful
because of lack of motivation and advice.
Another reason can be the inefficiency of the health
professionals to provide smoking counselling.

30. 5.Lack of interest in smoking intervention by Health
Professionals:
 They do not have time to provide smoking cessation during
clinical consultations.
 Myth among Health Professionals that giving unwanted
smoking cessation counselling may upset the clinician-patient
relationship.
6.Health professional’s own use of tobacco:
 13.5% of male medical
 11.4% of dental students
used tobacco.
In a study in kerala,
 15% of male medical
 13%of physicians
 14% of medical students
reported tobacco use.

31. SMOKING CESSATION INTERVENTIONS-
GUIDELINES AND GOALS:
The WHO expert committee on smoking control had
formulated certain guidelines in 1979 which recommended
the following:
1. 1.Non smoking should be regarded as normal social
behaviour and all actions which can promote the
development of this attitude are taken into
consideration.
2. There should be a total prohibition of all forms of
tobacco promotion.
3. Promotion of the export of tobacco and tobacco
products should be discouraged.Tobacco growing and
manufacturing industries should progressively be
reduced in size as rapidly as possible.

32. As per the US Public Health Service report, the aims of the smoking
cessation treatment should be as follows:-
1.The achievement of long term or permanent abstinence.
2.Effective treatment should be offered to all tobacco users.
3.There should be consistent identification ,documentation
and treatment of every tobacco user at each visit to the
hospital.
4.Brief tobacco dependence treatment is also effective and
thus should be offered.

33.  5.A strong relationship exists between the intensity of
tobacco dependence ,counseling and its
effectiveness.
 6.Practical counseling and social support , arrange
outside of treatment are helpful.
 7.Of all the effective pharmacotherapies ,atleast one
of these medications should be prescribed in the
absence of contraindications.
 8.Tobacco dependence treatments are cost effective
and should be covered by health insurance plans.

34. REGULATORY OR LEGISLATIVE APPROACH:
 India has a short history of tobacco related
legislation. But India has played a leadership role in
global tobacco control.
 With the growing evidence of harmful and
hazardous effects of tobacco ,the government of
India enacted various legislations and
comprehensive tobacco control measures.

35. 1) CIGARETTE ACT(regulation of
production,supply and distribution in 1975):
 First national Level
Anti-Tobacco
legislation.
 Passed in 1975
 Prescribed all
packages to carry
the warning.

36. 2) Pollution act:
 Introduced in 1988.
 Included smoking in the definition of air pollution.
3) Motor vehicle act 1988:
 Made it illegal to smoke and spit in a public vehicle.

37. 4)Tobacco prohibition act
of 1990:
 TOBACCO SMOKING WAS
PROHIBITED IN
 All health care
establishments,
 Educational instiutions,
 Domestic flights,
 Suburban trains
 Air conditioned buses

38. 5)Prevention Of Food Adulteration Act (PFA)
Amendment 1990:
Under The Prevention Of Adulteration
Act(PFA) Amendment 1990,statutory Warnings
Regarding Harmful Effects Were Made Mandatory
For Paan Masala And Chewing Tobacco.

39. 6)Drugs and cosmetics act 1940(amendment):
 In 1992.
 Use of tobacco in all dental products was banned.

40. 7)The Cable Television Networks(amendment ) Act
2000:
 Prohibited tobacco advertising in electronic media
and publications including cable television.
8)Revised smoke free rules:
 It came into effect from 2nd oct.2008.
 Included the ban on smoking in public places
including work place also.

41. 9)Cigarettes And Other Tobacco Products(prohibition Of
Advertisement And Regulation Of Trade And Commerce
, production ,Supply Distribution)act (COTPA),in 2003:
 The Indian Parliament passed the bill in April 2003.
 This bill became an act on 18 May 2003.

42. THE KEY PROVISIONS OF COTPA-2003 ARE AS
FOLLOWS:
1.)Prohibition Of Smoking In Public Places
Implemented From 2nd October 2008

43.  2.Prohibition Of Advertisement-direct Or Indirect
And Promotion Of Tobacco Products.

44. 2.)Prohibition of sales to minors(tobacco products
cannot be sold to children less than 18yrs of age and
cannot be sold within a radius of 100 yards of any
educational institutions

45. 3.)Regulation of health warning in tobacco products
pack . English and one more Indian language to be used
for health warnings on tobacco packs . Pictorial health
warnings also to be included.

46. 4.)Regulations and testing of tar and nicotine
content of tobacco products and declaring on
tobacco product packages.

47. 5.)Law pertaining to pictorial health warnings on
tobacco product packages:
 Implemented with effect from 31st May 2009.

48. NATIONAL TOBACCO CONTROL
PROGRAMME
 As the implementation of various provisions under
COTPA lies mainly with the state governments,
effective enforcement of tobacco control law remains
a big challenge.
 Government of India piloted National Tobacco
Control Program(NTCP) in 2007-2008.

49.  MAIN COMPONENTS:
At National Level:
1. Public awareness/mass media campaigns for
awareness building and behavior change.
2.Establishment of tobacco product testing
laboratory to build regulatory capacity,as mandated
under COTPA,2003.
3.Mainstreaming the program components as part of
the health care delivery mechanism under the
National Rural Health Framework.

50. 4.Mainstream Research and Training on alternate
crops and livelihoods in collaboration with other nodal
ministeries.
5.Monitoring an Evaluation including surveillance. e.g
Global Adult Tobacco Survey (GATS),India.

51. At State Level:
Tobacco control cells with dedicated manpower for
effective implementation and monitoring of anti tobacco
laws and initiatives.
At District Level:
1. Training of health and social workers,SHGs,
NGOs,School teachers.
2. Local IEC activities.
3. Setting up tobacco cessation facilities.
4. School programmes.
5. Monitoring Tobacco Control Laws.

52. WHO TOBACCO FREE INITIATIVE IN INDIA:
 The WHO Framework Convention on Tobacco
Control(WHO FCTC) is the first treaty negotiated
under the auspices of the World Health
Organisation.
 The WHO FCTC treaty opened for signature on 16
June to 22 June 2003 in Geneva , and when
closed,had 168 signatories which makes it the
most widely embraced treaties in UN history.

53.  The Convention entered into force on 27 Feb 2005.
 The WHO FCTC was developed in response to the
globalization of the tobacco epidemic. It asserts the
importance of demand reduction strategies as well
as supply issues.

54. THE DEMAND REDUCTION PROVISIONS ARE:
 Price and tax measures to reduce the demand
for tobacco,and
 Non-Price measures to reduce the demand for
tobacco namely:
 Protection from exposure to tobacco smoke.
 Regulation of the contents of tobacco products.

55.  Regulation Of Tobacco Product Disclosures.
 Packaging And Labelling Of Tobacco Products.
 Education,communication,training And Public
Awareness.
 Tobacco Advertising,promotion And Sponsorship.
 Demand Reduction Measures Concerning Tobacco
Cessation.

56. THE SUPPLY REDUCTION PROVISIONS ARE:
 To stop illicit trade in tobacco products.
 To stop sales to and by minors.
 Provision of support for economically viable
alternative activities.
 Article 14 of WHO FCTC also requires countries to
take effective measures to promote cessation of
tobacco use and adequate treatment for tobacco
dependence.

57.  Setting up of Tobacco Cessation Clinics in India
has been one of the major highlights of
WHO/Ministry of health and family welfare
collaborative programe in the area of tobacco
control.
 During 2001-02 a series of 13 Tobacco Cessation
Clinics were set up in 12 states across the country
in diverse settings such as Cancer treatment
hospitals,psychiatric hospitals ,medical colleges
,NGOs and Community settings to help users quit
tobacco use.

58.  This network of tobacco cessation clinics was
further expanded in 2005 to cover 5 new clinics in
Regional Cancer Centres (RCCs) in 5 states having
high prevalence of tobacco use.
 The Tobacco Cessation clinics were renamed as
Tobacco Cessation Centres and their role was
expanded to include trainings on cessation and
developing awareness generation on tobacco
cessation.

59.  The role of TCCs was further expanded in 2009 and
they were designated as Resource Centre For
Tobacco Control(RCTC).Many of them have
developed outreach programes for the community
and are regularly doing awareness programs at
schools ,colleges ,slums and work places.
 The emphasis is now being laid on mainstreaming
tobacco cessation in the Health Care Institutes to
set up tobacco cessation facilities in their respective
premises utilizing their existing infrastructure.

60.  Under GOI-WHO collaborative Tobacco Free
Initiative, consultants have been provided in 12 out of
21 NTCP states to support state governments in
implementation of the programme.
 WHO has also been supporting activities on World
No Tobacco Day(WNTD),every year on 31st May.

61. BEHAVIORAL MANAGEMENT
 This refers to the skills and techniques that are
critical to the care of all patients with nicotine
dependence.
 Initial intervention:
The National Cancer Institute advices a
5A based intervention in a primary care setup for
those who are willing to quit.
Smoking cessation programmes show a
predictable success rate of 40% or 20% with or without
nicotine replacement therapy respectively.

62. GUIDE TO COUNSELLING FOR TOBACCO CESSATION
5AS
ASK
ADVISE
ASSESS
ASSIST
ARRANGE

63. ASK
 Identification of patient’s
tobacco use
status(current,former) is the
first step.
 Check for the oral signs of
tobacco use:
• Stained teeth
• Halitosis
• Periodontal disease
• Discoloured patches on the
mucousa-
white,red,dark,precancerous
lesions.

64. FAGERSTORM TEST
 Used to score the cigarette addiction level.
 Based on answers to questions about
 Timing of first cigarette smoked in the day.
 Difficulty in not smoking in forbidden areas.
 Most important cigarette in the day.
 No. of cigarettes smoked in the day.
 Timing of most intense smoking.
 Smoking when ill.
Higher the scores indicate more addicted smokers

65. ADVISE
Clear, strong, personalized advice
to quit tobacco
• Clear: “My best advice is for you to
quit smoking.”
• Strong: “As your healthcare
provider, I need to you to know that
quitting smoking is the most
important thing you can do to
protect your health.”
• Personalized: Impact of smoking
on the baby, the family, and the
patient’s well being.

66. ASSESS
 Assess the patient’s willingness to quit within the
next 30 days.
 If a patient responds that they would like to quit
within the next 30 days, move to the Assist step.
 If a patient does not want to try to quit try to
increase their motivation.

67. ASSIST
 Suggest and encourage the use of problem-solving
methods and skills for tobacco cessation.
 Provide social support as part of the treatment.
 Arrange social support in the smoker’s
environment.
 Provide self-help tobacco cessation materials.

68. ARRANGE
 Follow-up to monitor progress and provide support.
 Encourage the patient.
 Express willingness to help.
 Ask about concerns or difficulties.
 Invite them to talk about their success.

69. SOMATIC TREATMENT:
 Pharmacotherapies can be divided into:-
Nicotine Replacement Therapy.
Medication that mimic nicotine effects.
Antagonists.
Medication that make intake aversive.

70. NICOTINE REPLACEMENT THERAPY
 Effective treatment to reduce cravings.
 Do not cause the subjective effects.
 Suppress the symptoms of nicotine withdrawal.

71. VARIOUS FORMULATIONS OF NRT ARE:
 Chewing Gum
 Sublingual tablets
 Lozenges
 Adhesive transdermal patches
 Nasal spray
 Nicotine inhalator cartridges

72.  Chewing gum:
 Available in 2 and 4 mg
 Nicotine is present in the form of a
complex with methacrylic acid
polymer(nicotine polacrilex)
 Persons who smoke 20 or
>cigarettes per day should start with
the 2mg strength gum,to be chewed
slowly over 30 when there is an
urge to smoke.
 Those smoking <20 cigarettes per
day should use 4mg gum.
 Has an unpleasant taste initially and
some find chewing difficult.
 Requires frequent doing and also
causes jaw pain and soreness of the
mouth.

73.  Sub lingual tablets:
 Equivalent of 2mg nicotine
 Recommended dose is 1-2
tabs sublingually.
 Can be increased to a
maximum of 40 tabs daily if
necessary for atleast 3
months.
 Dose should be gradually
reduced and then withdrawan.

74.  Lozenges
 Contain 1mg of nicotine(as
tartrate)
 Initial dose is one lozenge
every 1-2 hrs
 Can be increased upto a
maximum of 25 lozenges daily.
 Treatment should continue for
atleast for 3 months after which
it is gradually withdrawan.

75.  Adhesive transdermal patch:
 designed to be applied for 16-
24hrs.
 Available in different strengths ,
delivering 5-22 mg nicotine during
the recommended wear time.
 Patches are applied on the hip
,trunk, upper arm.
 Different site of application should
be used each day.
 Gradual withdrawal is
recommended by reducing the
dose every 2-8 weeks.
 Local untoward effects such as
itching and irritation may occur.

76.  Nasal Spray:
 suggested initial dose for a
nasal spray
(500µg/actuation) is one
spray into each nostril twice
an hour.
 Can be used upto a
maximum of 80 sprays daily
for the first 8 weeks and
reduced there after .
 May cause local irritation

77.  Nicotine inhalator
cartridges:
 Contain 10mg nicotine for
use in an inhaler.
 Initial dose is 6-16
cartridges/day for 12
weeks.
 Reduced gradually.
 Produces mouth and
throat irritation.

78. MEDICATION THAT MIMIC NICOTINE EFFECTS:
1.Bupropion Hydrochloride:
 Given as a modified release preparation(Bupropion SR)
 Initial dose is 150 mg once daily for 6 days , increasing
to twice daily on day 7
 Treatment should be started 1 week before the patient
attempts to stop smoking.
 If there is no significant progress towards smoking
abstinence by the 7th week , then therapy should be
stopped.

79. 2.Clonidine:
 Post synaptic a2 agonist that dampens sympathetic
activity originating at the locus ceruleus.
 0.1-0.4 mg/day for 2-6 weeks has been used.
3.Anxiolytics:
 Anxiety is a prominent sympton of nicotine withdrawal.
 So temporily replacing the anxiolytic effects of nicotine
with another medication during first week of cessation
might make cessation easier.
 Diazepam, Beta blockers have been widely used.

80. 4.Antidepressants:
 Many antidepressants have been tried with varied
results.
 Helpful only when the patients have underlying
depression.
5.Stimulants:
 Aim is to replace the stimulant effects of nicotine.
 Amphetamine is the most common drugs used,

81. 6.Anorectics:
 Initially were used to combat post cessation hunger and
weight gain.
 Encouraging results were obtained with fenfluramine and
phenylpropanolamine in short term trials.
7.Sensory replacement:
 Black pepper extracts,Denicotinised tobacco flavorings
all decrease cigarette craving and withdrawals.
 A citric acid inhaler has also been developed and
showed some promise in two clinical trials.

82. 8.Acupuncture:
Rationale behind is that acupuncture can release
endorphins that assist in cessation.
9.Devices:
Filters have been used to help smokers gradually
reduce the amount of smoking.

83. (C) ANTAGONISTS:
 Goal is to prevent cigarettes from producing
positive reinforcing and subjective effects.
 Mecamylamine
 Naltrexone

84. (D) MEDICATION THAT MAKE INTAKE AVERSIVE:
 Silver acetate combines with sulphides in tobacco
smoke to produce bad taste.

85. COUNSELLING THOSE UNWILLING TO QUIT:
MOTIVATIONAL ASSISTANCE “5R” APROACH
 Relevance of quitting
 Risk of continuing tobacco use.
 Reward of quitting.
 Roadblocks to quitting
 Repetion

86. CONCLUSION:
 Given the high global morbidity and mortality from
tobacco use in India,there is a need to develop
evidence based,cost effective interventions for both
smoking and smokeless tobacco use.
 Public health awareness , raising a mass
movement against tobacco , sensitizing and
educating all health care professionals for tobacco
control and cessation by incorporating the topic in
medical undergraduate curriculum,nursing
curriculum can have a huge impact.

89. REFERENCES:
 1.Kaur J and Jain DC.Tobacco Control Policies in
India:Implementation and Challenges(2011).Indian
Journal of Public Health55(3),220-21
 2.Jiloha.C.Tobacco Smoking:How far do the
legislative measures address the problem?(2012).
Indain Journal of Pschychiatry54(1),64-68
 3.Murthyp,saddichas.Tobacco Cessation Services
In India:recent Developments And The Need For
Expansion.(2010).Indian Journal Of Cancer 47,s69-
s74

90.  4.Kumar.R,prakash.S,kushwah S.A.Smoking
Cessation Control Measures.(2004),Lung India 22
:68-73
 5.Lal.G, Wilson C.Nevin And Gupta C. Attributable
Deaths From Smoking In The Last 100 Years In
India(2012). Current Science103(9) :1085-89
 6.Jiloha.R.Biological Basis Of Tobacco
Addiction(2010).Journal Of Psychiatry 52(4);301-04
 7.Peter.S: Essentials Of Preventive And Community
Dentistry;4th Edition:134-57

91.  8.Yadav.V,Pharmacotherapy Of Smoking Cessation
And The Indian Scenario(2006).Indian Journal
Pharmacol38(5):320-29
 9.Malhotra.R,Kapoor.A,Grover.V.Nicotine and
Periodontal Tissues(2010).Journal of Indian Society
of Periodontology14(1):72-79.
 10.Chaly.E.Tobacco Control in India(2007).Indian J
Dent Res18(1):2-5