TOBACCO ADDICTION
and
SMOKING CESSATION
DR.AYSE BAHA
Near East University Faculty of Medicine
The two biggest killers in the
world;
Hunger and Tobacco use
• World Health Organization: “All
epidemics have a route of transmission
and a tool that causes the spread of
disease and death.
• Regarding the tobacco epidemic, this
tool is not a virus, bacteria or other
microorganism
• “This tool is an industry and business
strategy.”
The smoking problem in
the world
• One-third of the adult of global population
smokers
• Over one billion people are smoking in the
world
• Every day, tobacco causes approximately
10,000 deaths throughout the world
• According to world bank database, tobacco
costs the global economy US $200 billion every
year
• Tobacco kills up to half of its users
• Tobacco kills more than 8 million people each
year, including an estimated 1.3 million non-
smokers who are exposed to second-hand
smoke.
• Around 80% of the world's 1.3 billion tobacco
users live in low- and middle-income
countries.
• In 2020, 22.3% of the world’s population used
tobacco: 36% of men and 8% of women.
What is Tobacco?
➢Tobacco is made by drying leaves from tobacco plants, and is the main component of cigarettes
• Cigaratte • Snuf
• Hookah • Snus
• Pipo • Kreteks
• Puro • rolling tobacco
• Bidi • chewing tobacco
HIT
Tobacco plant
Nicotine is the addictive ingredient.
Others are carcinogenic.
➢The toxins in cigarette smoke
reach every point in the body
where there is blood
circulation.
Not only our lungs,
but all our organs are at risk!
There are 3 types «smoking»
. First hand smoking
Active smokers
. Second hand smoking
Passive smokers
. Third hand smoking
• The sidestream smoke, that comes off a
SECOND-HAND SMOKING cigarette between puffs, have a higher
risk than directly inhaled smoke
(PASSIVE SMOKING)
• Second-hand smoke is a mixture of
sidestream smoke and the smoke
exhaled from the lungs of smokers
Consequences of secondhand smoke exposure
(passive smoking=second hand smoking)
In adults:
Stroke, lung cancer, infertility
In children:
• otitis media
• Lower respiratory tract diseases
• Impaired lung function
• sudden infant deaths
• Low birth weight and congenital orofacial
defects due to maternal tobacco use
9
• Made up of the pollutants that settle indoors when tobacco is
THIRD-HAND smoked.
• The chemicals in thirdhand smoke include nicotine as well as
SMOKING cancer-causing substances such as formaldehyde and others.
• Builds up on surfaces over time. It can become embedded in
most soft surfaces such as clothing, furniture, drapes, bedding
and carpets. It also settles as dust-like particles on hard surfaces
such as walls, floors and in vehicles.
• It can remain for many months even after smoking has stopped.
• It can't be eliminated by airing out rooms, opening windows,
using fans or air conditioners, or confining smoking to only
certain areas of a home.
• Traditional household cleaning often cannot effectively remove
thirdhand smoke from many surfaces.
• People are exposed to the chemicals in thirdhand smoke when
they touch contaminated surfaces or breathe in the gases that
thirdhand smoke may release.
• Infants and young children are at greater risk for exposure to
thirdhand smoke than adults due to activities such as crawling
and putting non-food items in their mouths. They also tend to
spend more time indoors.
Effects of Tobacco Use on Health
(FIRST HAND SMOKING)
• Cardiovascular diseases
• Malignancy
• Chronic lung diseases
• Digestive system diseases
• Musculoskeletal system diseases
• Cerebrovascular diseases
• Psychiatric diseases
• Fetal involvement during pregnancy
• Other
Malignancy
Direct proportion between the number of cigarettes smoked and malignancy
❖ 1 pack of cigarettes a day increases the risk of lung
cancer by 20 times
COPD
➢In COPD, the main cause is smoking. The risk of developing COPD is
directly proportional to the number of cigarettes smoked.
❖ Smoking cessation improves lung functions even after 60 YEARS!
Cardiovascular diseases
30% of heart disease-related deaths are smoking-related. MI risk is directly proportional to
the number of cigarettes smoked.
❖ By quitting smoking, the risk of sudden death decreases rapidly.
Cerebrovascular events
The risk of stroke is 6 times higher in those who smoke more than 1 pack of cigarettes per
day. In case of passive smoking, the risk increases by approximately 20-30%.
❖ The risk of stroke decreases rapidly after quitting smoking, reaching the same level
as a non-smoker within 5 years.
Diabetes mellitus
➢The risk of DM increases by 30% in case of exposure to cigarette
smoke.
Depression risk increases
Macular degeneration and cataracts risk increases
Rheumatoid Arthritis risk and exacerbation increases
TB risk and mortality risk increases
Decrease in fertility
• Directly proportional to the number
of cigarettes smoked
The consequences of smoking
during pregnancy;
Congenital anomaly
Mental retardation
Spontaneous abortion
Placenta previa
Premature membrane rupture
Low birth weight baby
➢Psychological factors
➢Social habits
➢ Three out of every four people who try smoking JUST once
are addicted.
Sigara Bırakma Tanı Ve Tedavi Uzlaşı Raporu, Türk Toraks
Derneği, 2014
DSM V-Tobacco Use Disorder Definition
➢The DSM-5 (American Psychiatric Association) defines tobacco use disorder
as a “problematic pattern of tobacco use leading to clinically significant
impairment or distress, as manifested by at least two of the following,
occurring within a 12-month period.”
DSM: The Diagnostic and Statistical Manual of Mental Disorders
Nicotine addiction/Fagerström Nicotine Dependency Test
➢Fagerstrom Dependency
Test is used to evaluate
nicotine addiction and its
severity.
➢This test is valuable in
determining the
approach to quitting
smoking and showing the
steps to be followed in
treatment.
Evaluation of patients who use tobacco
➢Cigarette addiction is defined as a
disease
➢Every physician should know the
approach
➢Tobacco use status of each patient
should be documented.
Evaluation of
patients who use The patient should be informed about the
tobacco harms of smoking in a non-oppressive
manner.
➢Smoking is a complex They should be encouraged to take action
behavior. and motivational meetings should be
held.
➢It has different
behavioral components Pharmacotherapy and behavioral support
treatment should be applied to the
such as initiation, patient at this stage.
cessation,
maintenance, At this stage, individuals should be
intermittent drinking congratulated and motivated
and relapse.
We must continue the fight
Sigara Bırakma Tanı Ve Tedavi Uzlaşı Raporu, Türk Toraks Derneği, 2014
Evaluation of patients who use tobacco
➢The approach to smoking patients should be individual.
➢2 strategies (smoking cessesition); 5A and 5R.
❖The 5A strategy should be applied to willing (want to smoking
cessation) patients.
❖The 5R strategy should be applied to reluctant patients.
Approach for patients willing to smoking cessation
5A
Evaluation of patients reluctant to quit
How to calculate smoking duration?
All patients should be asked if they smoke.
• How many years has he been smoking?
• How many cigarettes does the patient smoke per day?
• Examples;
• There are 20 cigarettes in a pack. If a person who smokes 1 pack of
cigarettes a day has smoked for 10 years, we multiply 10 and 1.
• We say that this person has smoked 10 p-y cigarettes.
• 2 pack a day, 30 years. (2x30: 60 pack year (p-y))
• 10 cigarette (half a pack) a day, 10 year (1/2 x 10: 5 p-y)
Smoking Cessation Treatment
=
Nicotine Addiction Treatment
NICOTINE
• It is a colorless, volatile, alkaloid liquid.
• It is a very powerful psychomotor stimulant
• Its effects can vary from person to person
• Generally include increased alertness, wakefulness, and, in some cases, enhanced creativity
• Nicotine users often develop strong dependencies
• Both physically and psychologically, leading to addiction.
• It makes neuronal stimulation via nAChRs.
• It has many pharmacological effects (passage through the blood-brain barrier)
• Nicotine causes addiction through central effects
Pharmacodynamics
of nicotine
• Nicotine increases dopamine levels.
• Dopamine means reward and pleasure!
• Nicotine increases serotonin and
norepinephrine.
• This creates an effect similar to an
antidepressant.
• When nicotine does not enter the body,
depressive symptoms and withdrawal
symptoms begin.
• When inhaled, nicotine reaches the
brain within 7‐10 seconds
• Via oral mucosa nicotine reaches
brain around 5‐10 min,
transdermal 10‐15 min
• Nicotine’s half‐life is approximately
2 hours
Plasma Nicotine Concentrations for Nicotine-
Containing Products
Nicotine Addiction Treatment
Who is more successful in quitting smoking?
• Those who are highly motivated
• Those who decide to quit within one month
• Those who live in places where smoking is banned
• Those who have non-smoking friends
31
Who is less successful in quitting smoking?
• Those who have failed before
• Those who have experienced severe withdrawal symptoms
• Those who have clinical psychiatric comorbidity
• Those who live or work in a stressful environment.
32
Nicotine Addiction Treatment
Behavioral and Cognitive Methods in Smoking Cessation Treatment
There are psychological, behavioral and neurobiological dimensions in
the pathogenesis of tobacco addiction.
Expected benefits from behavioral and cognitive treatments;
• Making the person want to get rid of the problem behavior
• To provide skills to those who want to quit tobacco use on ways to cope with
possible problems they may encounter in this process.
Nicotine Addiction Treatment
Behavioral and Cognitive Methods in Smoking Cessation Treatment
Fears during the quitting period;
• Withdrawal symptoms ❖ These problems can be overcome
with appropriate pharmacotherapy.
• Mouth sores
❖ Fiber diet is recommended
• Constipation
❖ It is recommended to consume 30% less food than before quitting.
• Weight gain ❖ It is recommended to eliminate increased appetite with calorie-free foods.
❖ It is recommended to take regular daily walks.
❖ It is recommended to suppress appetite by drinking water
What is tobacco abstinence?
A) Development of at least four of the following signs or symptoms within 24
hours after stopping or reducing the amount of tobacco use:
1. Irritability, frustration, or anger
2. Overwhelm
3. Difficulty focusing
4. Increased desire to eat
5. Restlessness
6. Depressed mood
7. Insomnia
B) Clinically significant distress or impairment in social, occupational, or other
important areas of functioning as a result of conditions in Criterion A
C) These symptoms and findings cannot be attributed to another health
condition or are not better explained by another substance withdrawal or
psychiatric disorder.
Pharmacological treatment
• Should all dependents undergo pharmacotherapy?
yes- except for contraindications
(those who smoke <10 cigarettes/d, women who are
pregnant and those breast-feeding, adolescents)
• Why should be given the pharmacotherapy?
Abstinence symptoms including insomnia, anxiety,
unhappiness, concentration difficulty, increased appetite, and
deppressive mood are at peak levels within the first 48 hours.
They may persist at this level for 1-3 weeks. Difficulty to
concentrate may persist for 2-3 months.
36
Pharmacotherapy
• Nicotine replacement treatments
• Nasal spray
• Oral inhaler
• Transdermal patch
• Lozenge
• Gum
• Varenicline
• Bupropion
37
Pharmacotherapy
There are 3 pharmacotherapy approaches with proven clinical efficacy:
•Nicotine replacement treatment (NRT)
• Replaces some of the nicotine that becomes deficient
• Facilitates easy quitting of smoking for nicotine addicts by slow and controlled dose reduction.
• In any form administered, nicotine is absorbed directly into blood.
• Varenicline
- is a nicotine receptor partial antagonist
- besides, it acts as a partial selective agonist for Alpha 4 and Beta 4 neuronal receptor sub-types
•Bupropion
• Affects the neurotransmitters associated with nicotine dependence and abstinence in the CNS
38
Nicotine dependence
Nicotine replacement
therapies (NRT)
gum, patch, nasal spray, inhaler, tablet
>100 study
The Cochrane Library
39
Nicotine replacement treatment
• Logical effect of NRT: reduces the symptoms of nicotine withdrawal and helps the
patient quit smoking, without having unpleasant withdrawal symptoms.
• At the second level, by reducing this dose gradually, nicotine dependence can be
overcomed
• The nicotine dose in NRT is lower than that in cigarettes.
• NRT never takes the place of cigarettes; however, in cigarette dependence, it helps
decrease the symptoms of nicotine withdrawal and craving by supplying your body
with nicotine.
• NRT is very safe and its dependence potential is not significantly important
40
The safety of NRT
• NRT is always much safer than continued cigarette smoking
• NRT does not contain the harmful chemicals that cigarettes possess; it only contains nicotine.
• Nicotine does not cause chronic respiratory disesases or cancer.
• The cardiovascular effects of nicotine are due to the form, the rate of delivery, and the blood
concentration. But none of these forms approaches to the toxicity levels as cigarette smoking.
41
NRT contrindications
• Absolute Patients with stable Coronary
• Recent MI
Artery Disease , pregnancy and
• Unstable angina
breastfeeding-
• Cardiac arhytmies
NRT may be a safe option if they
• Relative are still smoking
• Hiperthyroidy
• Peptic ulcus
• Severe renal and hepatic insufficiency
42
Nicotine replacement treatment-NRT
KEY points
• Nicotine is a stimulant that increases the heart rate, and contractility
• At doses below 63 mg, the patches are not associated with adverse effects.
• The recommended initial nicotine patch dosage for people who smoke more
than 10 cigarettes per day is 21-mg patch per day at the highest (30 patches -21
mg); one should then decrease the dose for the next 2-4 weeks. (14 and 7 mg)
• MI and rhythm disorders are not more common compared to smokers in
patients with CVS using NRT
• NRT is always much safer than continued cigarette smoking
43
Nicotine replacement treatment-NRT
SPECIAL WARNINGS
• During the post MI period, NRT should be used with caution in the first 2 weeks.
• A pregnant smoker may try NRT.
• In general, 8 weeks of treatment is sufficient. But if requied, it can be used for
12 weeks.
• Initially, two patches may be applied to smokers who smoke >2 packages daily.
44
NRT types
• Nicotine patch • Nicotine lozenge
• Nicoderm CQ (OTC) • Commit (OTC)
• Generic (OTC) • Generic (OTC)
• Nicotine gum • Nicotine inhaler
• Nicorette (OTC) • Nicotrol (Rx)
• Generic (OTC)
• Nicotine nasal spray
• Nicotrol NS (Rx)
OTC = over-the-counter / Rx=prescription required
no prescription needed
NICOTINE PATCHES-Nicotinell TTS 10/20/30
• Nicotine patches maintaine a stable blood level for 16 /24 hours.
• Apply the patch to a clean, dry, hairless area of the skin in the morning time
• To prevent local skin reactions, apply the next patch to a different skin area.
• It may cause nightmares in 15% of cases. The patinet can remove the patch
when going to bed
• Patient must never smoke while using nicotine skin patches
46
Nicotine Gum
• 2 mg (<25cig/day) and 4 mg (>25cig/day)
• Chew (release peppery taste) and “park”
• Absorbed in a pH basic environment, avoid acidic
beverages 15 minutes pre and post dose (coffee, juice,
soft drinks)
• Use enough pieces each day (10-15 usual)
Nicotine Gum Summary
Advantages Disadvantages
• Might be problematic for
◼ Might satisfy oral cravings. patients with significant
◼ Delays weight gain (4-mg dental work.
strength). • Patients must use proper
◼ Patients can titrate chewing technique to
minimize adverse effects.
therapy to manage
withdrawal symptoms. • Need for frequent dosing can
compromise compliance.
◼ A variety of flavors are
available. • Often under-dosed.
Bupropion (Zyban)
• It is the first generation antidepressant drug
• Bupropion decreases the neuronal reuptake of dopamine and noradrenaline.
• Inhibits the nicotinic cholinergic receptors in vitro.
• Decreases the nicotine withdrawal symptoms and cravings due to smoking
• Dose: 1x150 mg (3-7 days)
2x150 mg (7-12 weeks)
• It may interact with antidepressants, antipsychotics, antiarrhythmics, beta blockers.
• Contraindications: Epilepsy, Chr. Hepatic diseases, alcohol or benzodiazepine usage,
pregnancy, <18 years of age.
49
Bupropion Advers Effects
• Cardiovascular effects
– Minimal effect on blood pressure and heart rate
– No ECG changes have been reported
• Central nervous system
– Epileptic attack (0.1%)
– sleep disturbances
– headache
• Dermatological / Hypersensitivity
– Pruritis, urticaria, rashes
50
Varenicline (Champix)
• It is a partial nicotine receptor agonist and antagonist.
• Alpha 4 and Beta 4 neuronal receptor subtypes act as
selective partial agonists.
• These receptors have a role in nicotine dependence and
cravings for cigarette.
• The agonist effect decreases the withdrawal
symptoms.
• The antagonist effect decreases the pleasure effect of
smoking.
• Dosing : 1x0,5 mg (1-3 day)
2x0,5 mg (4-7 day)
2x1 mg (12 weeks)
51
Varenicline Adverse Effects
• Serious side effects: % 0.5
• Cardiovascular effects
– No effect on blood pressure and heart rate
– No ECG changes were reported
• Central nervous system
– Headache: % 12 -19 VARENICLINE IS NOT CURRENTLY IN USE.
– Sleep disturbances: % 5-21 THE DRUG WAS COLLECTED DUE TO THE
• Gastrointestinal system CLAIMS THAT IT CAUSES CANCER (BUT NOT
– Nausea: % 29-37 PROVEN)
– Vomiting: % 5
52
Another Tobacco Products
Hookah / Sheesha
It is tobacco that is smoked using a water pipe. Shisha Goza
The tobacco is usually sweetened and flavored
using additives.
Argileh Narghile
Other common names include: Shisha, Goza,
Argileh, Narghile, Water Pipes and Hubble-
Bubble. Hubble-bubble
Water Pipes
➢ 1 hour hookah smoking is equal 10-15
cigarettes
➢Hookah smoking have all the risks that
cigarette smoking have
54
Hookah and Infectious Diseases
Tuberculosis
Herpes
Hepatitis
Hookah Health Effects
Reduced Lung
Oral Cancer Stomach Cancer
Infection
Lung Cancer Esophageal Cancer Decreased Fertility
IQOS – Heated but not
burned tobacco product
▪ It gives the same taste and pleasure to smokers
like cigarette
▪ The company declares that is is less toxic than
cigarette
▪ Long-term exposure of IQOS, like
traditional cigarettes, caused a decline
in lung function, release of
inflammatory factors, oxidative and
antioxidant imbalance, and airway
remodeling
57
E- cigarette : global extent
• E-cigarette market in USA : $ 1,5
billion/year
• E-cigarette market worldwide: $ 10
billion/year
• People with anxiety and depression
are major customers
• Usage among high school students is
increasing rapidly
58
E-CIGARETTES COME IN MANY
DIFFERENT SHAPES
E-cigarettes are devices that
heat a liquid into an aerosol
that the user inhales.
E-cigarettes Make Aerosol, Not Vapor
Source: Quick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults | CDC
ALL TOBACCO PRODUCTS
ARE HARMFULL!
ATTENTION!!!
25 October 2024
Lesson time: 09.30 am
(PTE and Lung Cancer) (Dr.Ayse Baha)
--------------------------------
25 October 2024
Lesson time: 11:00 am
(Case reports) (Dr.Ali Uzan)
62
