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Smoking Cessation
- 1. Smoking Cessation Dr BhaktiMurkey Consultant Psychiatrist (MD)
- 2. Introduction Nicotiana tabacum(chief commercial plant of 70 known plant species) Considered sacred and having healing powers Used to ward off pests as it contains nicotine, a natural pesticide Given as welcome gift or as an offering to elders
- 3. What tobacco contains… Tobacco leaves are dried and fermented for use in tobacco products Nicotine: chief ingredient, mainly responsible for addictive use Other potentially harmful ingredients: Found in tobacco or created by burning it 4000 chemicals 40 cancer causing agents 500 poisons
- 4. Modes of consumption People can smoke, chew, or sniff tobacco Smoked tobacco products include cigarettes, cigars, bidis Some people also smoke loose tobacco in a pipe or hookah Smokeless tobacco: chewed tobacco products, also called snuff, dip or pinch (zarda/gutkha)
- 5. Statistics Globally, 40%of all deaths can be attributed to commercial tobacco use 50% of teens reported some type of cigarette use 21% of teens reported using smokeless tobacco Teens are 3 times more likely to smoke if a parent or sibling smokes Up to 50% of youngsters who try cigarettes go on to be daily smokers 85% of teenagers who smoke >=2 cigarettes a day and overcome the initial discomfort of smoking, will become regular smokers
- 6. Patterns of use Experimental use Recreational use Abuse Harmful use Dependence: Criteria: priority of use, inability to cut down, use despite adverse effects, tolerance and/or withdrawal Smoking more than a pack a day Smoking within 5 minutes of waking up Waking up at night to smoke Smoking to ease symptoms of withdrawal
- 7. How does tobaccoaffect the brain? Nicotine is absorbed through the lining of nose, mouth and lungs From there, it is readily absorbed into the bloodstream Nicotine initiates the release of hormone epinephrine (adrenaline) Epinephrine stimulates the CNS and increases blood pressure, breathing, and heart rate Nicotine also activates the brain’s reward circuits and increases levels of the chemical messenger dopamine, which reinforces rewarding behaviors Other chemicals in tobacco smoke, such as acetaldehyde, may enhance nicotine’s effects on the brain
- 8. Adverse effects Althoughnicotine is addictive, most of the severe health effects of tobacco use come from other chemicals RS: Tobacco smoking can lead to pneumonia, lung cancer, chronic bronchitis and emphysema CVS: It increase in risk of heart disease, including stroke or heart attack Immune system: Smoking has also been linked to several other cancers, even leukemia Smokeless tobacco increases the risk of cancer, especially oral cancers Others: Cataract, Type 2 Diabetes Risk applies to use of any smoked product, including hookah tobacco
- 10. Pregnant womenwho smoke cigarettes run an increased risk of miscarriage, stillborn or premature infants, or infants with low birth weight Smoking while pregnant may also be associated with learning and behavioral problems in exposed children Passive smoking: Secondhand smoke exposure can also lead to lung cancer and heart disease It can cause cough, pneumonia, reduced lung function and bronchitis Exposed children are at an increased risk of ear infections or severe asthma
- 11. Nicotine overdose: Uncommon Usually occurs in young children who accidentally chew on nicotine gum or patches used to quit smoking or swallow e- cigarette liquid Symptoms: difficulty breathing, vomiting, fainting, headache, weakness and increased or decreased heart rate
- 12. Benefits of quitting Within 20 Minutes: Blood pressure drops to normal Pulse rate returns to normal Body temperature of hands and feet increases to normal Within 8 Hours: Carbon Monoxide level in blood drops to normal Oxygen level in blood increases to normal Smoker's breath disappears Within 24 Hours: Chance of a heart attack decreases
- 13. Within 48Hours: Nerve endings start to re-grow The ability to smell and taste is enhanced Within 72 Hours: Bronchial tubes relax making it easier to breathe. Lung capacity increases making it easier to do physical activities Within 2 weeks -3 months: Circulation improves Walking becomes easier Lung function increases up to 30%
- 14. Within 3-9months: Coughing, sinus congestion, fatigue, shortness of breath decrease Energy level increases Cilia re-grow in lungs, increasing the ability to handle mucus, clean lungs, reduce infection Within 1 Year: Risk of coronary heart disease is half that of a smoker Within 2 Years: Heart attack risk drops to near normal Within 5 years: Lung cancer death rate for average pack-a-day smoker decreases by almost half Stroke risk is reduced Risk of mouth, throat and esophageal cancer is half that of a smoker
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- 16. Pre-contemplation: Personis unaware of any problem related to their smoking Unconcerned about the substance use Ignores anyone else’s belief that s/he is doing something harmful Stage of denial/ indifference Contemplation: Person is considering whether or not to change S/he enjoys smoking, but is sometimes worried about facing increasing difficulties Constantly debating with self whether or not s/he has a problem with addiction
- 17. Determination/Preparation: Personis deciding how s/he is going to change May be ready to change one’s behavior Getting ready to make the change It may take a long time to move to the next stage (action) Decision balancing may take up to a month’s time Action: Person has begun the process of changing Needs help with identifying realistic steps, high-risk situations and new coping strategies Successful implementation of an action plan may take 1-3 months of consistent efforts
- 18. Maintenance: Personhas made a change and is working on maintaining it Consistent change for at least 6 months Relapse: The person has reinitiated the identified behaviour (smoking) People usually make several attempts to quit before being successful The process of changing is rarely the same in subsequent attempts Each attempt incorporates new information gained from the previous attempts
- 19. Withdrawal symptoms Suddenfall in levels of nicotine in the bloodstream causes the body and mind to react to this withdrawal in the form of symptoms, both physical and psychological Though unpleasant, nicotine withdrawal has no health dangers Physical symptoms include: Headaches Sweating Restlessness Tremors Difficulty sleeping Increased appetite Abdominal cramps Digestive issues, including constipation Difficulty concentrating
- 20. These symptomsusually peak after 1–3 days and then decrease over a period of 3–4 weeks, after which the symptoms are mainly psychological The psychological symptoms of nicotine withdrawal include: Strong desire or craving for nicotine Irritability or frustration Low mood Difficulty concentrating Anxiety Mood swings
- 21. Cravings An irresistibleurge to smoke Significant factor in causing relapses Types: The steady and constant background craving for a cigarette (decreases in intensity over several weeks after quitting) Sudden bursts of an intense desire or urge to smoke are often triggered by a cue, like having a few drinks, feeling very happy or sad, having an argument, feeling stressed, or even having a cup of coffee Managing cravings: Nicotine Replacement Therapy Prescription medicines to stop smoking Cognitive and/or Behavior Therapy
- 22. Primary work:to identify factors that increase or decrease the sense of craving For example: exposure to symptoms, lack of sleep, food restriction can increase cravings Motivation, timely food, relaxation and exercise and use of coping strategies decrease cravings Coping strategies involve: Identifying a situation of high risk for craving Avoiding exposure to these risks Preparing a response to craving and Getting support
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- 24. Urge Surfing Abehavioral technique to avoid acting on unwanted urges Facts: Urges rarely last longer than 30 minutes if we don’t “feed” them by paying attention, planning to fulfill them, justifying, etc Whatever our mind repeats gets stronger, and whatever we don’t repeat gets weaker Suppressing a thought, feeling or sensation ultimately increases it Fighting urges (even by trying to talk oneself out of them or distracting from them) often makes them bigger Mindful understanding of urges can help with accepting them and ride them out without giving in
- 25. Ocean wave: Imagine that urges are like ocean waves that arrive, crest and subside They are small when they start, will grow in size, and then will break up and dissipate Surfers have to trust that the waves will eventually get smaller and reach the shore even when the waves feel large and overwhelming You can ride the “wave” by using the breath as a kind of surfboard until the urge passes
- 26. Cognitive Behavioraltherapy (CBT): Controlling the stimulus: recognizing the trigger situation (seeing others smoking, fatigue, drinking alcohol) Putting stimulus control strategies in place: Through avoidance (avoiding contact), Substitution (non-alcoholic drinks) and Change (drinking coffee in another place and time) Establishing cognitive strategies: repeating the list of motivations for quitting, thinking about something pleasant, self-encouragement etc Establishing behavioral strategies: urge surfing, changing the context, throwing yourself into a quick activity, doing relaxation breathing exercises, speaking to someone who is supportive
- 27. Motivation Enhancement Therapy MET is a counselling approach that helps individuals resolve their ambivalence about engaging in treatment and stopping their drug use Aims at evoking an internally motivated change Key focus on client’s commitment to implementing real change in pattern of substance use Principles: Empathy Reflection Feedback Building discrepancy Decision balancing Supporting self-efficacy
- 30. Find YourReason: We need a powerful, personally meaningful reason to quit It may be to protect your family from second-hand smoke Or lower your chance of getting lung cancer or heart disease Or to look and feel younger Choose a reason that is strong enough to outweigh your urges Call for reinforcements: Take help from a family member, friend or support group member in resisting the urge Chat on the phone, go for a walk together, share a few laughs, or get together to commiserate about your cravings
- 31. Give yourselfa break: One reason people smoke is that the nicotine helps them relax Once you quit, you’ll need new ways to unwind There are many options: exercise, music, socializing, pampering yourself, indulging in hobbies, etc If you usually smoked after meals, find something else to do instead at the time, like brushing your teeth, taking a walk, texting a friend, or chewing gum If you usually smoked while you talked on the phone, keep a pen and paper nearby to occupy yourself with doodling instead Stay motivated! Remind yourself of all the money you will save over years!
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- 33. Nicotine Replacement Therapy The key is to protect our body from exposure to harmful chemicals and taper the exposure to nicotine gradually, through replacement molecules Nicotine is available as: Skin patches Chewing gums Inhalators (which look like plastic cigarettes) Tablets, oral strips and lozenges Nasal and mouth spray
- 34. Patches releasenicotine slowly Some are worn all the time and some should be taken off at night Inhalators, gum and sprays act more quickly and may be better for helping with cravings Often the best way to use NRT is to combine a patch with a faster acting form such as gum, inhalator or nasal spray They are known to work better when combined Eligibility: most adults, children above 12 years of age, even pregnant women
- 35. Duration oftreatment: usually 8-12 weeks Possible side effects: Skin irritation with patches Irritation of nose, throat or eyes with nasal spray Sleep disturbance, sometimes vivid dreams Stomach upset Dizziness Headache
- 36. Role of Medication Varenicline (Chantix): Lessens the pleasure a person gets from smoking Reduces the symptoms of nicotine withdrawal Dose: 0.5 – 1 mg per day Typically start about a month to a week before your Quit Day. Taken after meals For 12 weeks usually, but can be repeated for another 12 weeks Reported side effects: nausea, vomiting, headache, sleep difficulties, constipation, mood swings
- 37. Bupropion (Zyban): Prescription antidepressant Reduces cravings and symptoms of nicotine withdrawal Dose: 150 – 300 mg per day Works best if started 1 or 2 weeks before Quit Day Longer course of few months for longer term effect This drug should not be taken if: seizures, heavy alcohol use, liver cirrhosis, or Bipolar mood disorder Reported side effects of Bupropion: dry mouth, stuffy nose, nightmares, headaches or anxiety
- 38. E-cigarettes Also knownas vaping devices, allow inhalation of nicotine vapors only Used to inhale an aerosol, which typically contains nicotine, propylene glycol and/or vegetable glycerine and flavouring in liquid form They do not burn tobacco and do not produce tar or carbon monoxide (two of the most damaging elements in tobacco smoke) Can help to manage nicotine cravings Certain e-liquids may contain nickel, chromium or cadmium, that can cause breathing problems Usually tightly regulated for safety and quality
- 39. Points to Remember Tobacco is a plant grown for its leaves; dried and fermented before use Contains nicotine, that leads to addiction People can smoke, chew, or sniff tobacco Nicotine acts in the brain by stimulating the release of adrenaline and dopamine Tobacco smoking can lead to lung cancer, chronic bronchitis and emphysema It increases the risk of stroke or heart attack Smoking has also been linked to other cancers, leukemia, cataracts and pneumonia Smokeless tobacco increases the risk of cancer, especially mouth cancers Both behavioral treatments and medication can help people quit smoking, but their combination is more effective
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