![Why people smoke / Is smoking a life style choice? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],M.J Jarvis, BMJ 2004;328:277-279 Heishman SJ. Nicotine Tob Res. 1999;1:S144 www.smokerclinic.com](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
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Smoking Cessation
- 1. Smoking Cessation !! How to become a real option ???? Dr. Assem Fouad El Esssawy Lecturer of Chest Diseases Fayoum University. www.smokerclinic.com
- 10. Modified Fagerstrom 1991 www.smokerclinic.com
- 15. Transdermal systems Acute systems www.smokerclinic.com Nicotine Replacement Therapy
- 20. Varenicline: A Highly Selective 4 2 Receptor Partial Agonist 1. Coe JW et al. Presented at the 11th Annual Meeting and 7th European Conference of the Society for Research on Nicotine and Tobacco. 2005. Prague, Czech Republic. 2. Picciotto MR et al. Nicotine Tob Res. 1999; Suppl 2:S121-S125. Binding of nicotine at the 4 2 nicotinic receptor in the VTA is believed to cause release of dopamine at the nAcc Champix is an 4 2 nicotinic receptor partial agonist, a compound with dual agonist and antagonist activities. This is believed to result in both a lesser amount of dopamine release from the VTA at the nAcc as well as the prevention of nicotine binding at the 4 2 receptors. Nicotine Chantix
- 22. Varenicline prescribing quit 500mcg 1 500mcg 2 3 days 4 days 1mg 2* reassess 11 weeks *reduce to 500 mcg 2 if side-effects but avoid abrupt withdrawal www.smokerclinic.com
- 23. 4-Week Continuous Abstinence Response Weeks 9–12 1 30 0 10 20 40 50 60 VAR 1 mg bid (n=352) 44.0% BUP 150 mg bid (n=329) 30.0% Pbo (n=344) 17.7% OR VAR vs Pbo 3.85 P <0.0001 VAR vs BUP 1.89 P <0.0001 OR VAR vs Pbo 3.91 P <0.0001 VAR vs BUP 1.96 P <0.0001 VAR 1 mg bid (n=344) 44.4% BUP 150 mg bid (n=342) 29.5% Pbo (n=341) 17.7% 30 0 10 20 40 50 60 CA Response rate (%) Study 1 Study 2 VAR=varenicline, Pbo=placebo, BUP=bupropion; OR = Odds ratio. 1. Champix Summary of Product Characteristics. Pfizer Ltd, Sandwich, UK. 2006. Nausea was reported by 28.6% of patients treated with varenicline 1 mg bid. The discontinuation rate for this adverse event was 2.7%. Nausea was generally described as mild or moderate. CA Response rate (%)
- 27. Weight and Smoking !! www.smokerclinic.com
- 36. Sunrise in Nicotine Addiction Treatment www.smokerclinic.com
Notes de l'éditeur
- For much of the 20 th century, smoking was regarded as a socially learned habit and as a personal choice or as a lifestyle choice Experimenting with smoking usually occurs in the early teenage years and is driven mainly by psychosocial motives. For a beginner, smoking a cigarette is a symbolic act conveying messages of adulthood or rebelliousness. Children who are attracted to smoking tend to come from backgrounds that favor smoking (high levels of smoking in parents, schools where smoking is common). They also tend not to be succeeding according to their own society rules (they have low self esteem, impaired psychological wellbeing, are overweight or poor achievers at school). By age of 20, 80% of cigarette smokers regret that they ever started, but as a result of their addiction to nicotine, many will continue to smoke for a substantial proportion of their lives. Nicotine addiction is a complex process, involving biological, psychological, cultural and behavioral factors. Smokers who try to quit experience decreased attention and cognition. It has been shown that impaired performance can be seen within 4 hours of enforced discontinuation of tobacco use, and impaired concentration, thinking, and performance brought on by nicotine deprivation are strong motivating factors to smoke a cigarette.
- Key Point Nicotine stimulates dopamine release in areas of the brain which is believed to result in the reward and satisfaction effect associated with smoking. Background After inhalation, nicotine preferentially binds to nicotinic acetylcholinergic (nACh) receptors located in the mesolimbic-dopamine system of the brain within a matter of seconds. Nicotine specifically activates 4 β 2 nicotinic receptors in the Ventral Tegmental Area (VTA) causing an immediate dopamine release at the Nucleus Accumbens (nAcc). 1 The dopamine release is believed to be a key component of the reward circuitry associated with cigarette smoking. 1 Reference 1. Picciotto MR, Zoli M, Changeux J. Use of knock-out mice to determine the molecular basis for the actions of nicotine. Nicotine Tob Res. 1999; Suppl 2:S121-125. 1/Picciotto, p. S121, para 1 1/Picciotto, p. S121, para 1
- Given tobacco’s carcinogenic properties, smoking has been an identified risk factor across an array of diseases and is causally linked to a host of cardiovascular, respiratory, reproductive, and other conditions, as well as many types of cancer. This includes its link to the top 3 smoking attributable causes of death in the United States 1) lung cancer, 2) ischemic heart disease, and 3) chronic obstructive pulmonary disease (COPD), respectively. Mortality from these conditions is considerable. For example, from 1995–1999, the top 3 smoking-attributable causes of death in the United States, respectively, were cancers of the lung, trachea, and bronchus (n=124,800 annually), ischemic heart disease (n=82,000 annually), and COPD (n=64,700 annually) 1 . Further details include: Ischemic stroke risk doubles for cigarette smokers, and hemorrhagic stroke risk increases 2 to 4 times vs nonsmokers. There is a synergistic effect of smoking on stroke risk in women using oral contraceptives. Passive cigarette smoke confers a doubling of risk for stroke approaching that of active smoking, and an &quot;exposure threshold&quot; rather than a dose-response relationship is observed 4 . There is a less obvious link, yet still a risk factor for smokers in areas such as osteoporosis, wound healing, peptic ulcers, metabolic syndromes, etc. The clear takeaway is that the risks of smoking posed on the body are not confined to any one system. References CDC. Surgeon General’s Report. The Health Consequences of Smoking: Executive Summary . 2004. CDC. US Department of Health and Human Services. The Health Consequences of Smoking. A Report of the Surgeon General. Atlanta, Ga: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004. Weitzman M, Cook S, Auinger P, et al. Tobacco smoke exposure is associated with the metabolic syndrome in adolescents. Circulation . 2005;112(6):862-869. Epub 2005 Aug 1. Goldstein LB, Adams R, Alberts MJ, et al. Primary Prevention of Ischemic Stroke. A Guideline from the American Heart Association/American Stroke Association Stroke Council. Cosponsored by the Outcomes Research Interdisciplinary Working Group Physical Activity, and Metabolism Council; and the Quality of Care and Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group. Stroke . 2006;37;1583-1633.
- C.I.= contraindication
- Bupropion may assist in helping patients to quit smoking because it reduces symptoms of depression associated with withdrawals. It is now considered first line therapy for smoking cessation while the strength of the evidence merits a rating A (Grade A) The target dose of this agent in nicotine dependence is 300 mg/day. Bupropion is started at least 7 days before the target quit day (TQD) at a dose of 150 mg once a day, and increased to 150 mg twice daily after 3-6 days so that steady-state levels are achieved before the quit attempt. The most serious adverse effect of Bupropion SR is seizure in 0.1% of users. common side effects include insomnia, ,agitation, dry mouth, headache, skinrash, pruritus, hypersensitivity and dizziness. The use of the drug is contraindicated in patients with history of epilepsy or in patients with seizure or under medication predisposing to a low threshold for seizure as well as in patients with a history of anorexia or bulimia, uncontrolled hypertension or severe hepatic necrosis. See next slide for smoking cessation rates (point prevalence) with placebo and Sustained-release Bupropion in different doses. (Hurt RD. A comparison of sustained-release Bupropion and placebo for smoking cessation. N. Engl J Med 1997;337(17):1195-202 A Cochrane review reveals that nortriltylline is an effective smoking cessation adjunct, with approximately equivalent efficacy to Bupropion. The efficacy of the drug is independent of its antidepressant effects. In studies of its use as an antidepressant, nortriptylline sometimes caused sedation, constipation, urinary retention and cardiac problems (an overdose can be fatal).
- Key Point Champix™ (varenicline) was deliberately designed for the 4 2 receptor, as an 4 2 nicotinic receptor partial agonist (with dual agonist and antagonist properties) and physically prevents nicotine from binding as an aid in smoking cessation. Background The initial view of the mesolimbic system identifies the VTA where the 4 2 receptors predominate, as well as the nAcc. The release of dopamine at the nAcc from the axons of the dopamine cells of the VTA is believed to produce a reward response. When nicotine binds at the 4 2 nicotinic receptor in the VTA, it is believed to cause release of dopamine at the nAcc. Champix™ (varenicline) was deliberately designed for the 4 2 receptor, as an 4 2 nicotinic receptor partial agonist (with dual agonist and antagonist properties) and physically prevents nicotine from binding and releases intrinsically less dopamine at the nAcc. References Coe JW, Brooks PR, Wirtz MC, et al. Varenicline (CP-526, 555): A novel, potent, and selective nicotinic receptor partial agonist for the treatment of smoking cessation: Rationale, discovery, and mode of action. Presented at the 11th Annual Meeting and 7th European Conference of the Society for Research on Nicotine and Tobacco, March 20–23, 2005, Prague, Czech Republic. Picciotto MR, Zoli M, Changeux J. Use of knock-out mice to determine the molecular basis for the actions of nicotine. Nicotine Tob Res. 1999; Suppl 2:S121-S125.
- Key Point In both studies, varenicline resulted in continuous abstinence (CA) rates at weeks 9 through 12 that were significantly higher than for placebo or bupropion. Background For the primary end point of carbon monoxide (CO)–confirmed, 4-week CA rates were defined as patient report and exhaled CO <10 ppm. 4-week CA rates with varenicline treatment were significantly higher compared with bupropion treatment or placebo. 1 In study 1, 44.4% of participants in the varenicline group were continuously abstinent from smoking during weeks 9 to 12 compared with 29.5% of participants in the bupropion group and 17.7% of participants in the placebo group (both P <0.0001). This translated to an abstinence OR of 3.91 for varenicline vs placebo and an OR of 1.96 versus bupropion. 1 Similarly, in study 2, 4-week abstinence rates for varenicline, bupropion, and placebo were 44.0%, 30.0%, and 17.7%, respectively. Varenicline was significantly more effective compared with placebo (OR, 3.85; P <0.0001) and bupropion (OR, 1.89; P <0.0001). 1 Subjects were provided with an educational booklet on smoking cessation and received up to 10 minutes of smoking cessation counseling at each clinic visit in accordance with Agency for Healthcare Research and Quality Guidelines. Reference 1. Champix Summary of Product Characteristics. Pfizer Ltd, Sandwich, UK. 2006. 1/Champix Summary of Product doc/p. 7/¶7/Table 1/Champix Summary of Product doc/p. 7/¶7 /Table