TOBACCO CESSATION

Presented by:M.Jyothi, PG III yrGuided by: Dr. Yadav sir.

CONTENTS

• INTRODUCTION• WHAT IS TOBACCO ?• HISTORY OF TOBACCO• TYPES OF TOBACCO USE• TOBACCO BURDEN

▫ GLOBAL▫ INDIAN

• HARMFULL EFFECTS OF TOBACCO USE▫ SMOKE FORM▫ SMOKELESS FORM▫ PASSIVE SMOKE(SECOND HAND SMOKE)▫ THIRD HAND SMOKE▫TOBACCO AND PREGNANCY

• PREVENTION AND CONTROL OF TOBACCO USE• TOBACCO DEPENDENCE• BEHAVIOURAL INTERVENTIONS• STRATEGIES FOR TOBACCO CESSATION - THE 5 “A”S AND

5 “R”S• STEP 1: ASK• STEP 2: ADVISE

▫ BENEFITS OF QUITTING• STEP 3: ASSESS

▫ ASSESSING A TOBACCO USER’S READINESS TO CHANGE THE BEHAVIOUR.THE STAGES OF READINESS TO CHANGE MODEL

▫ ASSESSMENT OF NICOTINE DEPENDENCE— IF THE TOBACCO USER IS IN THE READY STAGE

• STEP 4 – ASSIST• PHARMACOTHERAPY• NON PHARMACOLOGICAL CESSATION STRATEGIES • WITHDRAWAL SYMPTOMS • FOR TOBACCO USERS WHO ARE NOT READY TO MAKE A

QUIT ATTEMPT▫ THE 5 “R”S APPROACH

• STEP 5: ARRANGE• SELF HELP IN INTERVENTION FOR TOBACCO CONTROL• SMOKELESS TOBACCO HOW TO QUIT??• TOBACCO CESSATION IN DENTAL CLINIC• TOBACCO CESSATION IN SPECIAL SITUATIONS • GLOBAL TOBACCO CONTROL• TOBACCO CONTROL IN INDIA• CONCLUSION• REFERENCES

INTRODUCTION

• Tobacco is the major cause of preventable mortality and morbidity all

over the world

• The World Health Organization (WHO) estimates that annually nearly

5 million people are killed by tobacco-related illnesses.

• If current trends continue, it is projected that by 2030, tobacco will be

responsible for more than 8 million deaths each year

• Tobacco use is a global epidemic that kills 5.4 million people annually,

tragically, more than 80% of those deaths occurs in the developing

countries.

• In India, trends in consumption of tobacco, incidences of tobacco

related cancers and other illnesses

• Tobacco-related mortality in India is among the highest in the

world, with about 700,000 annual deaths attributable to smoking in

the last decade (Gajalakshmi et al., 2003), expected to increase to

1million in the current decade.

• About half of teenagers who use tobacco will eventually be killed

by it.

• Annual oral cancer incidence in the Indian subcontinent has been

estimated to be as high as 10 per 100,000 among males (Moore SR

et al, 2000) and oral cancer rates are steadily increasing among

young tobacco users.

1990 2020

1%

13%Deaths in India due to tobacco

deaths

• Passive smoking causes health problems for children and other

family members.

• The burden will not just be in terms of death and illness but also

reduced productivity and increasing health-care costs.

• However, all is not lost. If effective tobacco control measures, along

with treatment, are made available, and the adult tobacco

consumption halves, millions of deaths can be prevented.

Tobacco and its history:

• It is thought to be derived from the Arabic word tabaq, meaning

euphoria producing herb.� �• Cultivation of the tobacco plant probably dates back 8000 years by

American Indians through the southern and northern American

continent.

• It belongs to family Solanaceae, night shade family

• Native Americans began using tobacco for medicinal and

ceremonial purposes before 1 BC.

• The documentation of the practice of inhaling the smoke of dried

tobacco plants is available from the Mayan culture as early as the

sixth century.

• Christopher Columbus in 1492 first observed these tobacco

leaves.

• In 1493, Ramon Pane, who accompanied Columbus first person to

introduced tobacco seeds into Europe.

• Through Columbus crew journey of tobacco went to Spain and

introduced its cultivation in Spain.

• Jean Nicot was instrumental in introducing tobacco into Europe.

• He cured migraine pain using powdered tobacco.

• The tobacco plant thus got its generic name, Nicotiana after Jean

Nicot.

• Though the tobacco plant came to Europe through Spain, smoking

as a habit became popular in the continent from England.

• Portuguese traders introduced tobacco in India during 1600.

Tobacco became a valuable commodity in barter trade and its use

spread rapidly.

• Gradually tobacco got assimilated into the cultural and social

practices due to presumed medicinal and actually addictive

properties attributed to it.

Medicinal attributes of tobacco:

• In the sixteenth century a leading physician of Seville, Nicolas

Monardes, reported the medicinal properties of tobacco, identifying

25 ailments that tobacco could cure ranging from toothache to � ��cancer.

• According to the European humoral system of medicine all diseases

were believed to be caused due to imbalances, e.g. excess heat and

excess moisture.

• Tobacco was believed to have the power to expel excess moisture

from the body.

• The Chinese YangYin (hot -cold) medical system also classified � �tobacco to be having similar medicinal properties and effects on

body.

• Our Indian ayurvedic system even followed hot & cold system but

never recommended medicinal use of tobacco.

• A description of the tobacco plant, its medicinal values and adverse � �effects is found in Yogaratnakara

• It is said to facilitate smooth intestinal functioning and motion,

prevent toothache by killing germs, cure itching on the skin, control

wind in the body.

• Adverse effects of tobacco use are also indicated in this work such

as giddiness, weakening in eyesight, and making semen less virile.� �

TYPES OF TOBACCO USE

Smoked forms of tobacco use:

• Bidis, Cigarettes, Chuttas, Dhumti, Chillum, Hookah.

Smokeless forms of tobacco use:

• Paan with tobacco, preparations, Gutkha, Mawa, Khaini, Mishri

etc

BURDEN

Global

• 1/3rd of world population-Smoker

▫ Males: > 1 billion

▫ Females: > 250 million

• Industrialized Countries

▫ % of Male smokers: 50%

▫ % of Female smokers 22%

• Developing countries

▫ Males 31%

▫ Females 8%

• 6 million die each year

• >80% deaths occurring in developing countries

• Ten million deaths annually expected by 2020 - means one death

after every three seconds.

• In 2013 study showed that the majority of young children in low-

and middle-income countries could correctly identify cigarette

brand logos, and nearly a third of children in India reported that

they wanted to smoke when they grow up.

INDIA

• There are almost 275 million tobacco users in India(2009-2010).

• Among adults (age 15+), over one-third (35%) of the population use

tobacco products, with 48% of males and 20% of females using

some form of tobacco.

• Among youth (age 13-15), 4% smoke cigarettes (boys 5%; girls

2%).

• Almost 12% of youth use other types of tobacco products (boys

14%; girls 8.5%).

• Bidis are the most popular tobacco product used. Bidis comprise

48% of the tobacco market, chewing tobacco 38% and cigarettes

14%.

HARMFULL EFFECTS OF TOBACCO USE

1) Smoke form

2) Smokeless form

3) Passive smoke(second hand smoke)

4) Third hand smoke

SMOKE FORM The major health effects of cigarette smoke include:

• Cancer; • Noncancerous lung diseases; • Atherosclerotic diseases of the heart and blood vessels;• Toxicity to the human reproductive system.

Important constituents and effects:

• Nicotine: Powerful addictive drug. Causes increase in heart rate and

blood pressure. Has adverse effects on cardiovascular health.

• Carbon monoxide: Acts as an added stress factor to precipitate

cardiovascular disease. It combines with haemoglobin to form

carboxyhaemoglobin, which reduces the oxygen carrying capacity

of the blood.

• Hydrogen cyanide: Respiratory irritants that paralyses ciliary

movement.

• Acrolein: Respiratory irritants that paralyses ciliary movement.

• Phenol: Respiratory irritant and tumor-producing chemical.

• Polyaromatic hydrocarbons (PAHs), particularly benzopyrenes:

Potent lung carcinogen.

• Tobacco–specific Nitrosamines (TSNAs): Carcinogen.(NNN)

• Nickel, Arsenic, lead, cadmium, chromium etc

• Tar, polonium 210, vinyl chloride, benzene etc

• Nitric oxide, ammonia, hydrogen cyanide etc

SMOKELESS FORM

• The major health consequences associated with smokeless tobacco

use include.

• Cancers of several sites (e.g. the upper respiratory and digestive

tracts)

• Poor reproductive outcomes.

• Blood pressure and cardiac disease.

• In addition, use of areca nut, often chewed with tobacco, can

predispose to diabetes mellitus and aggravate asthma.

Adverse effects on pregnancy:

• Threefold increase in stillbirths and a 100–400 g decrease in birth

weight, in off springs of women who chewed tobacco during

pregnancy.

Asthma:

• Asthma patients who chew betel quid with or without tobacco may

find their condition aggravated by the arecoline from areca nut,

which induces the contraction of bronchiolar smooth muscle.

Second-hand and Third-hand smoke:

• Secondhand smoke is the smoke that comes from the burning end of

a cigarette, cigar or pipe. It is also the smoke that smokers breathe

out (exhale).

• Third-hand smoke is the invisible tobacco “dust” (or chemical) that

settles in the environment and stays there even after a cigarette has

been put out.

• The smoke from the burning end of a cigarette has more toxins than

the smoke inhaled by the smoker.

• Affect young infants and children adversely.

• Presents health hazards comparable to smoking.

• Also contains toxins and carcinogens, and breathing it in for as little

as 20 or 30 minutes can cause harm.

• Health risks include cancer (including cancer of the nasal sinuses),

cardiovascular diseases and lung disease(Asthma)

• More susceptible to both upper and lower respiratory tract infections

and have reduced lung function.

• Middle ear infections are also more likely in children living in

smoking households.

• chronic cough, wheezing, eye and nose irritation, and irritability are

the other problems.

TOBACCO AND PREGNANCY

Smoking form of tobacco useThe effects include higher risk of • Abortion or Miscarriage• Ectopic pregnancy• Stillbirths• Intrauterine growth retardation• Prematurity• Low birth weight.• Birth defects such as cleft palate and digital anomalies.• There is a greater risk of sudden infant death syndrome (SIDS),

particularly in children born to mothers who actively smoke during pregnancy.

• Reduced lung function in infants, and may lead to increase in the

number of respiratory tract infections during infancy.

• Impaired lung function during childhood and adulthood.

• Smokeless tobacco use during pregnancy has also been shown to

have a range of adverse reproductive outcomes, including

1) increased rates of stillbirths

2) prematurity and

3) lower birth weight.

PREVENTION AND CONTROL OF TOBACCO USE

• Tobacco use is a leading cause of preventable deaths all over the

world.

• Tobacco is also one of the major causes of deaths and diseases in

India, accounting for almost a million deaths every year.

• Global Adult Tobacco Survey (GATS) India (2010) data revealed

that more than one out of three adults in India (35%) used tobacco

in some form or the other.

• Among them, 21 % of adults used only smokeless tobacco, 9% only

smoked and 5 % smoked as well as used smokeless tobacco.

• Indian males 48 % females 20 %.

• As per the Global Health Professions Student Survey (GHPSS),

India, 2009

• 6.5% third year dental students smoked cigarettes and 8.6% used

other tobacco products.

• Among medical students, 13.4% third year medical students smoked

cigarettes and 11.6% used other tobacco products.

• Global Youth Tobacco Survey(GYTS) India, 2009 revealed that

14.6% of 13-15 years school going children in India used tobacco

products out of which 4.4% smoked cigarettes and 12.5% used other

forms of tobacco.

TOBACCO DEPENDENCE

• Tobacco dependence is defined as, “Cluster of behavioral, cognitive

and physiological phenomena that develop after repeated tobacco

use and that typically include a strong desire to use tobacco,

difficulties in controlling its use, persistence in tobacco use despite

harmful consequences, a higher priority given to tobacco use than

other activities and obligations, increased tolerance and sometimes a

physical withdrawal state”.

• Both smoked and smokeless forms of tobacco contain nicotine, a

highly addictive chemical, making it difficult for habituated tobacco

users to quit.

• Nicotine is readily absorbed from the respiratory tract, buccal

mucosa and skin.

• Inhaled nicotine takes about 10-19 seconds to reach the brain and its

stimulation releases chemicals which ensure feeling of goodness,

alertness and energy.

• As the person stops tobacco use, these chemicals decrease in the

body and withdrawal symptoms start.

• These can be very distressing for the unprepared tobacco user.

• Thus, the tobacco user is compelled to continue using tobacco,

hence trapped in the vicious cycle.

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TOBACCO DEPENDENCE TREATMENT

• Tobacco smoking is a learned behaviour that results in a physical

addiction to nicotine for the majority of smokers.

• Tobacco dependence is a chronic condition that often requires

repeated interventions.

• Because effective tobacco dependence treatments are available,

every patient who uses tobacco should be offered at least one of

these treatments.

• Accordingly, stopping smoking can be difficult for many

individuals, and it is recommended that interventions include

behavioural and pharmacological support.

• when seeking to quit abruptly, a combination of behavioural

support and pharmacotherapy is recommended.

• Tobacco dependence treatments are both clinically effective and

cost effective in relation to other medical and disease prevention

interventions.

• Costs per quality adjusted life year (QALY) for all smoking

cessation interventions (brief and more intensive and those

including pharmacotherapy) are low.

• BEHAVIOUR INTERVENTIONS:

• Smoking cessation interventions are commonly influenced by

theories of behaviour change, including the Transtheoretical model,

the Health Belief Model and/or Social Cognitive/Learning theory.

• Health belief model(Becker): This model proposes that when an

individual considers changing behaviour they engage in cost/benefit

analysis of situation.

• It suggests that before a change to take place there needs to be a

trigger to initiate the alteration.

• Social cognitive theory(Bandura): explains how individuals

initiate and maintain a given behaviour (i.e., quitting smoking) by

emphasizing the role of interactions among various cognitive,

environmental, and behavioural factors .

• Cognition: Various mental processes that occur within the

individual, such as behavioural capability, outcome expectancies,

emotional coping responses, and feelings of self-efficacy.

• Behavior: The manner in which the individual reacts to various

inputs from their social and/or physical environment (i.e., self-

regulation).

• Environment: Any factor physically external to the individual that

can impact one’s behaviour. The environment is comprised of social

factors (i.e., family, friends, observational learning), and physical

factors (i.e., weather, availability of tobacco products, etc.)

• Operant conditioning theory( Skinner): A rein forcer is any

situation or stimulus that strengthens a given response or behaviour

that precedes it.

• This helps to monitor their behaviour in order to identify and alter

the emotional and environmental cues that trigger the urge to smoke

along with the rein forcers that support the habit

PRIME theory:

• Nicotine from cigarettes generates the motivation to smoke and

undermines self-control by interacting with all of the level of

motivation.

• It creates stimulus-impulse associations resulting in cue-driven

urges; impairs inhibitory control; gives enjoyment resulting in

‘wanting’ to smoke; it leads to ‘nicotine hunger’, withdrawal

symptoms and beliefs about benefits of smoking (e.g. stress relief)

all of which can result in a ‘need’ to smoke.

• Understanding the multiple aspects of addiction requires an

understanding of human motivation.

• Many people conceptualise human motivation in terms of decisions

to do or not do things based on an analysis of their costs and

benefits

• However, it is clear that much behaviour is driven by habit or

instinct in which one just responds without thinking about the

consequences and often our actions are driven by feelings of desire

rather than judgements about what would be the best option.

• a model of human motivation that encapsulates these different

aspects of motivation In recent years, West and colleagues have

promoted the PRIME theory of motivation.

• This has been developed to overcome the deficits of previous

models.

• PRIME theory considers cigarette addiction to be a disorder of

motivation and it seeks, through a conceptualization of smokers’

plans, responses, impulses, motives, and evaluations to help

practitioners understand what they can do to help patients/clients

overcome their addiction

STRATEGIES FOR TOBACCO CESSATION - THE 5 “A”S AND 5 “R”S

• The Five A’s (Ask, Advise, Assess, Assist and Arrange)

• Five R’s (Relevance, Risk, Rewards, Repetitions, Roadblocks) is a

five to fifteen minute counseling approach that has proven global

success.

STEP 1: ASK

• Systematically identify all tobacco users at every visit.

• It should be an essential part of evaluation that for every tobacco

user at every consultation.

• Tobacco use status be queried and documented.

• STEP 2: ADVISE “STRONGLY URGE ALL TOBACCO USERS TO QUIT”.

Advice should have:

1-Clear Message

2-Strong message

3- Personalized message

Tell them about benefits of quitting.

• BENEFITS OF QUITTING

• It is important to tell the tobacco user about the benefits of quitting.

• Begin thus - From the moment you quit smoking, it only takes 20

minutes for your body to start undergoing beneficial changes.

20 Minutes:

• Blood pressure drops to normal; Pulse rate drops to normal;

Temperature of hands and feet increases to normal.

Within 8 Hours:

• Carbon-monoxide level in blood drops to normal; Oxygen level in

blood becomes normal.

Within 24 Hours to 48 hours:

• Chance of heart attack decreases.

• Ability to smell and taste begins to improve.

Within 72 hours:

• Bronchial tubes relax, making breathing easier.

Within 2 Weeks to 3 Months:

• Circulation improves. Lung function increases up to 30%

Within 6 Months:

• Coughing, sinus congestion, fatigue and shortness of breath decrease.

The lungs function better, as congestion reduces, so does the chance

of infection.

Within 1 Year:• Risk of coronary heart disease decreases to half that of a smoker.

Within 10 Years:• Risk of dying from lung cancer is reduced to half.

Within 15 Years:• Risk of dying from a heart attack is equal to a person who never

smoked.

STEP 3: ASSESS

• Assess: Determine willingness to make a quit attempt.

• To be able to assist a tobacco user with tobacco cessation, assess his/

her willingness to commit to this change.

• Ask every tobacco user if he/she is willing to make a quit attempt at

this time (e.g. within the next 30 days)

• The stages of Readiness to change model is a valuable model for

assessing a tobacco user’s readiness to change the behaviour.

• Cessation is explained as a process, and tobacco users may go

through the steps of being ready, quitting and relapsing, an average

of three to four times, before achieving success.

• Tobacco users will be in different stages of readiness at different

times, hence, readiness needs to be re-evaluated constantly.

• The stages may be,

i ) Not ready (Pre contemplation)

ii) Unsure (Contemplation)

iii) Ready (Preparation)

iv) Action

v) Maintenance.

Assessment of nicotine dependence:

• Assess willingness to quit, and determine the level of Nicotine

addiction. This can be measured by Fagerstrom Scoring. The tool

has six simple questions. Scoring is done as followed:

1-A high level of addiction will rank between 7 and 10 points.

2-A medium level between 4 and 6 points.

3-A low level between 0 and 3 points.

STEP 4 – ASSISTThe following strategies are suggested to assist tobacco users in

motivational stage:

Help in making a QUIT PLAN: Preparations for quitting;1) Set a quit date; ideally, the quit date should be within 2 weeks.2) Tell family, friends, and co-workers about quitting, plan and seek

their support.3) Anticipate challenges to planned quit attempt, particularly during

the critical first few weeks. These include nicotine withdrawal symptoms.

4) Remove tobacco products from surroundings.5) Avoid – Avoid Smoking or Using tobacco in places where a lot of

time is spent e.g. work place. Avoid all forms of tobacco, do not substitute one tobacco product for another.

• Provide practical counseling (Problem solving / skills training)

• Past quit experience-Identify what helped and what failed in

previous quit attempts.

• Anticipate triggers or challenges in upcoming attempt – Discuss

challenges and how user will successfully overcome them.

• Alcohol- The tobacco user should consider limiting/abstaining from

alcohol while quitting.

• Other tobacco users in household/ workplace.

• Provide intra treatment social support- supportive environment is

provided

• Help in obtaining extra treatment social support- provide help in

social support, ask spouse, friends to support you in your quit

attempt.

• Recommend Pharmacotherapy: Explain how the medications

improve success rates and reduce withdrawal symptoms.

PHARMACOTHERAPY• Approved drugs for smoking cessation:Nicotine replacement therapy (NRT)• Nicotine gum, patch, lozenge, nasal spray, inhaler

NON - NRT1-Psychotropics• Sustained-release bupropion2-Partial nicotinic receptor agonist• Varenicline

NRT: PRODUCTS:• Polacrilex gum• Nicorette (OTC)• Generic nicotine gum (OTC)• Lozenge• Nicorette Lozenge (OTC)• Nicorette Mini Lozenge (OTC)• Generic nicotine lozenge (OTC)• Transdermal patch• NicoDerm (OTC)• Generic nicotine patches (OTC, Rx)• Nasal spray• Nicotrol NS (Rx)• Inhaler• Nicotrol (Rx)

NICOTINE GUM

• Resin complex

Nicotine

Polacrilin

• Sugar-free chewing gum base

• Contains buffering agents to enhance buccal absorption of nicotine

• Available : 2 mg, 4 mg

• Flavors :original, cinnamone, fruit, mint (various), and orange

NICOTINE LOZENGE

• Nicotine Polacrilex formulation

• Delivers 25% more nicotine than equivalent gum dose

• Sugar-free mint, cherry flavors

• Contains buffering agents to enhance buccal absorption of nicotine

• Available: 2 mg, 4 mg

TRANSDERMAL NICOTINE PATCH

• Nicotine is well absorbed across the skin

• Delivery to systemic circulation avoids hepatic first pass

metabolism

• Plasma nicotine levels are lower and fluctuate less than with

smoking

NICOTINE NASAL SPRAY• Aqueous solution of nicotine in a 10-ml spray bottle

~100 doses/bottle• Each metered dose actuation delivers

▫ 50 µL spray▫ 0.5 mg nicotine▫ Rapid absorption across nasal mucosa

NICOTINE INHALER

• Nicotine inhalation system consists of:

1-Mouthpiece

2-Cartridge with porous plug containing 10 mg nicotine and 1 mg

menthol

3-Delivers 4 mg nicotine vapor, absorbed across buccal mucosa

Dose and duration Side effects contraindications

1- nicotine gum

1-24 cigarettes – 2 mg gum(upto 24 pieces /day)for 12 weeks>25 cigarettes-4mg gum(upto 24 pieces/day)for 12 weeks

Mouth soreness, throat irritaton , dyspepsia, nausea, vomiting

Gastric ulcers, MI or stroke in past two weeks

2-nicotine patch

21 mg/24 hrs for 4 weeks then 15mg/24 hrs, 7mg/24hr for 2 weeks

Local skin irritation, insomnia

MI or stroke in past two weeks

3- nicotine inhaler

6-16 cartridges/day for 6 months

Local irritation of mouth and throat

As above

4-Nicotine nasal spray

1-2 doses/hour 3 to 6 months

Nasal irritation, irritation - of throat, coughing and watering of eyes.

As above

Non nicotine replacement therapy:

BUPROPION SR

• Oral formulation• Atypical antidepressant that has both dopaminergic and adrenergic

actions. • Quit date is set 7-14 days start of treatment.• 150 mg OD for 3 days followed by 150 mg BD for 7-12 weeks• Clinical effects↓ craving for cigarettes↓ symptoms of nicotine withdrawalSide effects: agitation, restlessness, GI upset, anorexiaContraindicated – history of allergy, undergoing alcohol withdrawal,

preganant and lactating women

VARENICLINE

• Partial nicotinic receptor agonist that binds to α and β nicotinic

acetylcholine receptors in brain

• Oral formulation 0.5 mg OD for first 3 days, increased to 0.5 mg twice

daily for next 4 days, 1 mg twice daily for 12 weeks.

• Clinical effects

↓ symptoms of nicotine withdrawal

• Tobacco use can be stopped one week after initiating treatment.

• Side effects: agitation, depression

• Contraindicated in pregnant and lactating women.

Combination Therapy:

• Combined behavioural and pharmacological therapies appear to be

the best approach for treating tobacco dependence.

• Because these therapies operate by different mechanisms,

complementary and potentially additive effects may be expected

• Nicotine Replacement Therapies (NRT) combined with supportive

counselling are the most widely used and intensively reached

treatment method

WITHDRAWAL SYMPTOMS:

• Commonly experienced withdrawal symptoms on stopping tobacco use include:

Depressed moodInsomniaIrritability, frustration , angerAnxietyCraving and difficulty in concentrationRestlessnessDecreased heart rateIncreased appetite or weight gain

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Non-Pharmacological Cessation Strategies:

• Tapering - Cut down the number of cigarettes/bidis smoked (or

smokeless tobacco) each day until the client finds they are no longer

using it.

• Cold Turkey - Abruptly stopping all smoking. Best for clients who

smoke two packs of cigarettes a day or less. Cold turkey is the

simplest and, for most people the easiest way to quit.

Tobacco cessation part 2

NOT WILLING TO QUIT

THE 5 “R”s APPROACH

• For tobacco users who are not ready to make a quit attempt, provide

a brief intervention designed to promote the motivation to quit and

information about harmful effect of tobacco.

• The tobacco user may have fears and concerns about quitting, or

may be demoralized because of previous unsuccessful attempts and

relapse.

• 5 “R”s; i.e. Relevance, Risk, Rewards, Roadblocks and Repetition.

Relevance:

• Encourage the tobacco user to consider the personal relevance of

cessation. Take into account the disease status (if any), family or

social situation, health concerns, age and gender.

Risks:

• Discuss risks of continued tobacco use, including effects of

exposure to second hand smoke on the family members especially

children. Relate with the symptoms.

Rewards:

• Encourage tobacco user to identify benefits of cessation.

Roadblocks:

• Barriers that the tobacco user may face in his/her quit attempt

should be identified.

• Withdrawal symptoms, fear and concern associated with quitting,

depression, lack of social support, enjoyment of tobacco are some of

the barriers that the tobacco user may face in an attempt.

• Repetition: This information should be reviewed regularly with

tobacco users who are not yet ready to quit. It is also important for

tobacco users who have not yet successfully quit to understand that

most people attempting cessation quit several time before finally

succeeding in quitting.

STEP 5: ARRANGE

• Arrange - Schedule a follow-up contact

• Time- Follow up contact should occur soon after the quit date,

preferably during the first week. A second follow up contact is

recommended within the first month.

• Follow up visits after advice to quit have been shown to increase the

likelihood to successful long term abstinence.

• During the follow up, quitters have some common problems and a

solution should be suggested accordingly.

Hypothesized Mediators of the Relation Between SES and

Smoking Cessation

• Social Support: Individuals of low SES report fewer close social

relationships and use their support network to a lesser extent than

individuals of higher SES

• Additionally, greater social support has consistently been shown to

have a positive influence on smoking cessation (Gulliver 1986)

• Social support may influence smoking cessation by increasing self-

efficacy(Gulliveretal.,1995;Sorensen,Barbeau,Hunt,& Emmons,

2004) and reducing negative affect/stress

• Neighborhood Disadvantage: Overall, individuals of lower SES

report greater exposure to neighborhood problems are more vigilant

for threat in their neighborhoods, and perceive less neighborhood

social cohesion than do those of higher SES.

• recent studies have indicated that neighborhood disadvantage is

associated with an increased likelihood of smoking and engaging in

other detrimental health behaviors (Ellaway & Macintyre, 2009)

Michael S. Businelle et al. Mechanisms Linking Socioeconomic Status to Smoking Cessation: A Structural Equation Modeling Approach. Health Psychology 2010, Vol. 29, No. 3, p.g.no 262–27.

• Negative Affect/Stress:• Numerous studies have shown that negative affect and stress are

associated with both SES and smoking cessation• Individuals of lower SES tend to report more stressors and greater

overall negative affect in relation to those of higher SES (Gallo & Matthews, 2003)

• Agency: self-efficacy for quitting smoking has been linked to SES and is an important predictor of smoking cessation.

• individuals with higher levels of education report higher confidence in their ability to quit smoking.

• Craving:

• Although little is known about the relationship between SES and

craving, some research has shown that tobacco advertising is often

more prevalent in low-SES neighborhoods (Laws, Whitman,

Bowser, & Krech, 2002).

• It is possible that SES may have an indirect influence on nicotine

craving through exposure to tobacco advertisements.

Self help interventions for tobacco cessation:

• 1- minimal clinical intervention

• 2-intensive clinical intervention. This includes

a) Individual behavioural counselling

b) Supportive group sessions / group behaviour therapy

c) Aversion therapy

Others : 1-Telephone counselling

2- New technologies (txt2stop; txt2quit)

• Minimal clinical intervention: It is based on 5 ‘A’ approach.

• Brief advice/ intervention by health professionals.

• Involves in assessing their current tobacco use, advice them to stop,

offer assistance, referring to specialist

• Duration is 3-5 min

• Barrier for this procedure is lack of time, lack of skills & training.

• Intensive clinical intervention: More intensive behavioural

methods has been used to support patient attempts at smoking

cessation in clinical settings.

• Individual counselling: provided by specialist counsellors, not by

health care provider.

• Duration is 10 min.

• Review participants tobacco history, identifies high risk situation

and generates appropriate problem solving strategies.

• Supportive group sessions: Offers individuals to learn behavioural

techniques for tobacco cessation

• Led by professional facilitators, clinical psychologists, health

educators, nurses, doctors.

• It includes: sets up specific quit date.

• Learning to interrupt conditioned responses that support tobacco

• Make plans for coping with temptations to smoke following

cessation

• Provide follow up contact and social support.

• Aversion therapy: Adding an unpleasant stimulus to an attractive

behaviour reduces attractiveness and may extinguish behaviour.

• Rapid smoking is advised where they are asked to take puff for

every 6-10 sec for 3 min until they consume 3 cigarettes.

• Repeated 2-3 times and asked to concentrate on unpleasant

sensations it causes.

• Others: smoke holding, excessive smoking, behavioural treatment

with bitter pills.

Telephone counselling: They provide support and encouragement to

individuals who smoke and want to quit.

• Increased frequency of calls increases likelihood of person quitting

when compared with self help materials/ pharmacotherapy alone.

• Beneficial route for who may be time poor/ limited financially

resources.

New technologies: With the advent of smart phones, easy internet use

of text messaging( txt 2 stop, txt 2 quit) has been developed in

U.K,U.S.A

Lei Wu et al. Effectiveness of additional follow-up telephone counselling in a smoking cessation clinic in Beijing and predictors of quitting among Chinese male smokers . BMC Public Health (2016) 16:63

Smokeless tobacco and how to quit: • Smokeless tobacco comes in 2 basic forms, snuff and chewing

tobacco.Harmful health effects include:• oral (mouth) cancer • pancreatic cancer • addiction to nicotine • leukoplakia (white sores in the mouth that can become cancer) • receding gums (gums slowly shrink away from around the teeth) • bone loss around the roots of the teeth • abrasion (scratching and wearing down) of teeth • tooth loss • stained teeth • bad breath

Nicotine replacement therapy

• These include:

• nicotine gum

• nicotine patch

• nicotine lozenges

• nicotine inhaler

• nicotine nasal spray

Other medicines

• Bupropion

• Varenicline

Tobacco cessation in dental clinic:

• In the clinic ,dentists have an important role in helping patients quit

tobacco and, at the community and national levels, to promote

tobacco prevention and control strategies.

• Dentists in the clinic

• See the harmful effects of tobacco on the mouth Are in an ideal

position to counsel patients

• See children and youth as patients and can influence them to adopt a

tobacco-free lifestyle

• Treat women of childbearing age and can inform them of the

dangers of tobacco use during pregnancy

• Can build their patients’ interest in discontinuing tobacco use by

showing them the actual effects in the mouth

• Have a duty to promote oral health and healthy lifestyles among their

patients.

• Dentists in the community and nation:

• Can be role models by not using tobacco or by quitting successfully.

• Tobacco use by dentists is a significant barrier to tobacco cessation

counselling.

• Can speak with authority in the community about the dangers of

tobacco use

• Dental treatment often necessitates frequent contact with patients

over an extended period of time, providing a mechanism for long-

term contact and reinforcement, coupled with visible changes in the

oral cavity in response to counselling.

• studies report that adolescents consistently rank physical

attractiveness, dental concerns, and oral health as greatly important

• Relating smoking to short-term adverse effects such as staining of

teeth, bad breath, loss of taste may be more relevant and meaningful

than relating smoking to long-term health effects such as

cardiovascular or lung diseases.

• Dentists should provide messages about tobacco use that are

appropriate to the patient's age and developmental stage.

• A congratulatory message positively reinforced can truly enhance

the chances of a child desisting from tobacco use in the future

Tobacco cessation at special situations:

• 1- pregnant and lactating women

• 2- Cardiovascular disease

• 3-people with smoking related disease

• 4-People with mental illness

• 5-People with substance-use disorders

• 6-Weight gain apprehensive patients

• Other therapies: Hypnosis, Acupuncture, Yoga

GLOBAL TOBACCO CONTROL

• Global Surveillance

• Framework Convention for Tobacco Control (FCTC)

• World Health Organization’s MPOWER Package

• Global Youth Tobacco Survey

• The purpose of the Global Youth Tobacco Survey (GYTS) is to

enhance countries’ capacity to monitor youth tobacco use, guide

national tobacco prevention and control programs, and facilitate

comparison of tobacco-related data at the national, regional, and

global levels.

• GYTS began in 1998 with a meeting between WHO and CDC,

which concluded that there was a need for surveillance of tobacco

use among adolescents 13-15 year old.

• The survey is been done using the core questionnaire consisting of

54 questions.

• Overall, 12 percent of boys currently smoke cigarettes and Overall,

nearly 7 percent of female students currently smoke cigarettes. The

rates are highest in the regions of Europe and Western Pacific, and

lowest in those of Eastern Mediterranean and South-East Asia.

• When asked for tobacco cessation 69% of current smokers would

like to stop the habit.

• The WHO Report on the Global Tobacco Epidemic, 2008 urges

countries to: “establish programmes providing low-cost, effective

treatment for tobacco users who want to escape their addiction.”

• Yet only nine high-income or middle-income countries, covering

only 5 percent of the world’s population, offer complete cessation

services to adults or youth. This leaves 95 percent of people without

access

• Global Health Professional Survey:

• WHO+ CDC+ Canadian public health association developed to

collect data on tobacco use and cessation counseling among health

professionals in all WHO member states.

• It included students of dentistry, medicine, nursing, pharmacy and

among them 3rd year students included.

• It uses core questionnaire

• Global School Personnel Survey:

• Data collected by the Global School Personnel Survey (GSPS)

between 2000 and 2008 have shown that an alarming proportion of

school personnel smoke cigarettes and use other forms of tobacco.

• About one-fifth of school teachers and administrators currently

smoke cigarettes.

• Twice as many male teachers as female teachers smoke cigarettes

and use other tobacco products.

• The majority of GSPS school personnel have not received specific

training to help students avoid or stop using tobacco, but strongly

agreed that they should receive training.

• Most teachers reported that they do not have adequate teaching

materials to support prevention and reduction in tobacco use.

• Global Adult Tobacco Survey (GATS)

• The Global Adult Tobacco Survey (GATS) is a nationally

representative household survey that was launched in February 2007

• It enables countries to collect data on adult tobacco use and key

tobacco control measures

• GATS has been implemented in more than 25 low- and middle-

income countries with highest burden of tobacco use.

Topics covered in GATS:

• Tobacco use prevalence (smoking and smokeless tobacco products).

• Second-hand tobacco smoke exposure and policies.

• Cessation.

• Knowledge, attitudes and perceptions.

• Exposure to media.

• Economics.

• Global Adult Tobacco Survey (GATS) India (2010) data revealed

that more than one out of three adults in India (35%) used tobacco

in some form or the other.

• Among them, 21 % of adults used only smokeless tobacco, 9% only

smoked and 5 % smoked as well as used smokeless tobacco.

• Overall tobacco use is much higher among Indian males at 48

percent but is also a serious concern among females among whom

prevalence is 20 per cent

Framework Convention on Tobacco Control (FCTC)

• The first international agreement on tobacco control, and the first

treaty ever negotiated by WHO.

• Developed in response to the globalization of the tobacco epidemic.

• Designed to promote national and global cooperation to counter the

worldwide tobacco epidemic.

Time line:• May 1999: World Health Assembly called for work to begin

• May 2003: WHO’s 168 member states unanimously adopted the treaty

• February 27, 2005: Treaty entered into force

• India is a signatory to FCTC and it joined in 2003.

Key Provisions of the FCTC• Comprehensive bans on tobacco advertising, promotion, and

sponsorship within 5 years of ratification (some exceptions)

• Bans use of misleading and deceptive terms such as “light” and “mild”

• Rotating health warnings required on packs that cover 30% or more of the package and can include pictures or pictograms

• Protection from exposure to SHS in workplaces, public transport, and indoor public spaces

• Encourages tobacco tax increases

• Prohibits sale to minors

• Strengthens legislation to combat smuggling

• Calls for testing, measuring, and regulating the contents and emissions of tobacco products

WHO MPOWER Package

• 2008 Report –first in a series of WHO reports to track the status of tobacco epidemic and impact of interventions

• Highlights global scope of the epidemic –“Tobacco is the single most preventable cause of death in the world today.”

Six policies of WHO MPOWER package:

▫Monitor tobacco use and prevention policies▫Protect people from tobacco smoke▫Offer help to quit tobacco use▫Warn about the dangers of tobacco▫Enforce bans on tobacco advertising, promotion and sponsorship▫Raise taxes on tobacco

• WORLD NO TOBACCO DAY

• In 1987, WHO designated May 31 as World No Tobacco Day to

draw global attention to the health risks of tobacco use.

• Objective of celebrating the World No Tobacco Day all over the

world is

• to promote and encourage the common public to reduce or stop the

use of tobacco or its products consumption as it may lead to the

some lethal diseases (cancer, heart problem) or even death

• Various countries and tobacco cessation programmes:

• Seychelles: The country’s Tobacco Control Act of August 2009

created completely smoke-free environments in all enclosed public

places and workplaces, on all transport, and in selected outdoor

premises including all health and educational facilities

• Tobacco advertising, promotion and sponsorship are also

completely banned, formalizing the absence of tobacco advertising

that has been observed for several decades and extending it to new

forms of tobacco marketing.

• Comprehensive tobacco control legislation was first drafted in the

Seychelles in 1996 but it was passed in assembly in june 2009.

• Turkey: It began providing comprehensive tobacco dependence

treatment that includes a national quit line as well as coverage of

costs for nicotine replacement therapy and at least some other

cessation services.

• Phlippines: The Philippines has a strong and well-developed health

surveillance infrastructure

• National Nutrition and Health survey using the WHO STEPs

survey instrument shows that the Philippines’ tobacco use

monitoring system includes periodic, recent and representative

smoking prevalence data for both adults and youth, ranking the

country in the highest category of monitoring effectiveness.

• New zealand provides a wide range of free cessation services as

part of its comprehensive tobacco control strategy.

• New zealand first introduced nationally funded cessation

programmes in the late 1990s: a national quit line service

• The national quit line (http://www.quit.org.nz) now assists more

than 50,000 New zealanders each year who attempt to quit smoking

• Smoking prevalence among adults in 2009 was 21%, a decline by

about a third over the past two decades that resulted from sustained

strong tobacco control policies and high-quality cessation services.

Urguay Mauritius

Turkey Russia

India

TOBACCO CONTROL IN INDIA

• Legislation for tobacco control started evolving in India in the mid-

1970s.

• This was in response to increasing scientific evidence of tobacco

being a major cause of mortality and morbidity in the world,

growing awareness of the adverse health effects of tobacco

consumption in India and rising demands for tobacco control

elsewhere in the world.

• 1975: Cigarettes (regulation of production, supply and distribution) Act.

• 1980: Central and state governments imposed restrictions on tobacco trade and initiated efforts for comprehensive legislation for tobacco control.

• 1990: Central government issued directive prohibiting smoking in public places, banned tobacco advertisements on national radio and TV channels, advised state governments to discourage sale of tobacco around educational institutions and extended the display of statutory health warning to all chewing tobacco products.

• 1999: High Court of Kerala announced ban on smoking in public places.

• 1999: Ministry of Railways banned sale of cigarettes and bidis on railway platforms and in trains.

• 2000: Central government banned tobacco advertisements on cable television.

• 2001: Supreme Court of India mandated a ban on smoking in public places.

• In February 2001, Indian Prime Minister Vajpayee’s union cabinet introduced Cigarettes and other Tobacco Products Bill.

• 2001: Ministry of Railways imposed ban on sale of gutkha (a packaged chewing tobacco) in railway stations, inside trains and on railway premises.

• 2001-2003: Production and sale of chewing tobacco products banned in states of Tamil Nadu, Andhra Pradesh, Maharashtra, Madhya Pradesh, Bihar and Goa using the provision of the Prevention of Food Adulteration Act.

• 2002: tobacco cessation clinics were established for first time (13) expanded to 19 now

• 2003: The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act (COTPA), 2003 was introduced.

• 2003: India became a signatory to Framework Convention on Tobacco Control (FCTC)—one of the first ten countries in the world to do so.

• 2007: India defers pictorial health warning issue repeatedly. It is now expected to be implemented from May 31st 2009.

• 2008: Revised smoke-free rules implemented that defined public places and identified people responsible for maintaining smoke-free work places. The government announced that all public places across the entire country would go smoke-free.

• 2007-2008: Govt of India intiated National Tobacco control programme

Training centres• Training modules for doctors and health workers were also

developed in 2010-11 emphasizing the “brief advice” for tobacco

cessation.

• National Institute of Mental Health and Neurosciences

(NIMHANS) Bangalore offers a one month orientation course for

health professionals

• There a few known certified programs that are provided, one by

Directorate of Distance Education Annamalai University,

Tamilnadu, post graduate diploma program in health sciences

(Tobacco Control) (Annamalai University, 2011).

• The Public Health Foundation of India (PHFI), a public private

organization in collaboration with John Hopkins Bloomberg School

of Public Health and University of Southern California, USA has

introduced six month short term courses on tobacco control for

health professionals.

• For the first time, tobacco cessation was also incorporated in the

training modules of doctors under the Revised National

Tuberculosis Control Programme (RNTCP).

Role of Health Professionals• One of the strategies to reduce morbidity and the number of

smoking-related deaths is to encourage the involvement of health

professionals in tobacco use prevention and cessation counselling

• Many studies have shown that counselling with a health

professional is an effective method of helping smokers quit

• GATS survey 2009-2010 revealed that who visited a health care

provider, 46.3% of smokers and 26.7% of users of smokeless

tobacco were advised to quit .

How Oral Health Professionals Can contribute

• Dental care practitioners are a largely untapped resource for

providing advice and brief counselling to tobacco-using patients

• As dentists may see their patients on a frequent and recurring basis.

it is been suggested that dental personnel have unparalleled

opportunities to educate and help those who use tobacco to quit .

• Randomized clinical trials have found that even brief dental office-

based interventions can be effective in motivating and assisting

tobacco users to quit (Carr and Ebbert, 2006).

• Barriers: a number of studies have reported that delivery by health

care professionals is often suboptimal.

• The reasons are multiple but include time and service constraints

• Also, a key barrier is often that professionals have not had

appropriate training and and/or lack confidence in their own ability

to raise the issue of smoking cessation and provide appropriate

information and advice.

New Initiatives and Re-Direction of The Old Initiatives

• 1-Incorporation of oral health into tobacco prevention policies

• 2-Integration of tobacco cessation techniques into group and

community settings

• 3-Setting up of 24 hour quit-lines

• 4-Setting up of tobacco cessation clinics at private dental

institutions through inclusion into dental curriculum

• 5-Team approach in tobacco cessation

• 6-Financial measures to discourage tobacco consumption

• 7-Tobacco awareness campaigning at school and colleges - Creating

Policies for a Tobacco-Free Campus

• 8-Extension of tobacco cessation services to the rural areas through

primary health care centres

• 9-Setting up of mobile oral health services with multidisciplinary

teams for people in the rural areas

Sukhvinder Singh Oberoi et al. Tobacco Cessation in India: How Can Oral Health Professionals Contribute? Asian Pac J Cancer Prev, 15 (5), 2383-2391

Conclusion:• Tobacco smoking remains a major contributor to premature

mortality and significantly adds to the global burden of disease and disability.

• All professionals have a role in providing brief smoking cessation advice and education. Support to prepare for and during a quit attempt is best provided by health professionals with the appropriate knowledge and skills.

• Health care providers need to work with people who smoke to assist them in choosing the most helpful modality as a patient centered approach to smoking cessation

References

• Burden Of Smoked And Smokeless Tobacco Consumption In India - Results From The Global Adult Tobacco Survey India (GATS-India)- 2009-2010.

• WHO Report On The Global Tobacco Epidemic, 2011

• Tobacco: Global Trends: ASH Research Report, 2011.

• History Of Tobacco 19th 20th 21st Century.

• Cigarette Smoke Components and Disease: Cigarette Smoke Is More Thana Triad of Tar, Nicotine, and Carbon Monoxide, Smoking and Tobacco Control Monograph No. 7, Chapter 5, p59-75.

• The War Against Tobacco, A Progress Report From The Indian Front, The Economist Intelligence Unit 2009

• Tobacco Dependence Treatment Guidelines, National Tobacco Control Programme, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India.

• Training Manual Doctors, National Tobacco Control Programme, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India.

• World Health Organization, Regional Office for South-East Asia Helping People Quit Tobacco: A Manual for Doctors and Dentists.

• ASH Research Report January 2012: Tobacco and Oral Health

• Addiction To Nicotine, WHO.

• Helping People Quit Tobacco: WHO Regional Office South East Asia.

• Health Effects Of Tobacco, And Exposure To Tobacco Smoke Nicotine, And Tobacco Smoke Pollution, Jonathan Foulds, Handbook Of The Medical Consequences Of Alcohol And Drug Abuse, 2008, Chapter 13.

• The Health Consequences Of Involuntary Exposure To Tobacco Smoke A Report Of The Surgeon General.

• Ebbert J, Montori VM, Vickers-Douglas KS, Erwin PC, Dale LC, Stead LF, Interventions for smokeless tobacco use cessation (Review), The Cochrane Library 2009, Issue 1.

• Report on Tobacco Control in India, Ministry of Health & Family Welfare, New Delhi, India

• Economic History Of Tobacco Production In India.

• Tobacco Cessation Services In India: Recent Developments And The Need For Expansion Murthy P, Saddichha S, Indian Journal Of Cancer ,2010, Volume 47, Suppl 1.