الطريقي الحميدي باتل حسامالرحيلي الشمري فارس سعدبخش الشهري ياسر عمار

Smoking Smoking التدخينالتدخين

Smoking epidemic is one of the biggest public health threats the world has ever faced.

It is the leading preventable cause of death in many countries.

Every Day 13,000 people die .

It kills nearly six million people each year. more than 5 million are users and ex users and more

than 600.000 are nonsmokers exposed to second-hand smoke.

1 Billion Man in the world smoke !! About 35% of men in developed countries

and 50% of men in developing countries .

250 Million woman in the world smoke !! About 22% of women in developed

countries and 9% of woman in developing countries .

It caused 100 million deaths in the 20th century. If current trends continue, it will cause up to one billion deaths in the 21st century.

Nearly 80% of the more than one billion smokers worldwide live in low- and middle-income countries, where the burden of tobacco-related illness and death is heaviest.

95 % of the global population is unprotected by laws banning smoking.

Nicotine Multiplies the effect of various neurotransmitter

Dopamine Noradrenaline Chronic nicotine administration develop

tolerance .

Mechanism of addictionMechanism of addiction

State of nicotine deprivation Altered level of dopamine Noradrenaline Other neurotransmitter

Causes of the withdrawal Causes of the withdrawal symptoms :symptoms :

Hussam Alhamidi

Effects on body systemEffects on body system

Major factor in many diseases and adverse health events .

There is sufficient evidence that smoking causes the following conditions :

Cancers :• lung,• oral (laryngeal)• GI (esophageal, stomach, liver, pancreatic) • GU (bladder, kidney, cervical)• hematologic (myeloid leukemia)

Cardiovascular disease: • atherosclerosis • cerebrovascular • coronary heart disease(CHD)• abdominal aortic aneurysm

Respiratory disease:

• chronic obstructive pulmonary disease(COPD)

• increased susceptibility to pneumonia

• impaired lung growth during childhood and adolescence

Reproductive effects:• decreased fertility in women, • complications of pregnancy:such as o premature rupture of the membranes o placenta previao placental abruption o miscarriageo still birtho low birth weight o reduced lung function in infants o sudden infantdeath syndrome (SIDS)

Other:• hip fractures• low bone density• peptic ulcer disease • cataracts• diminished health

status

269,000 deaths among men

243,000 deaths among women

Lung cancer represents the biggest cause of smoking-related cancer mortality.

According to the (CDC), smoking-related lung cancer accounts for more than 10 times the number of years of potential life lost (YLL) in the United States compared with any other smoking-related cancer

Difference in lung cancer risk between smokers and former smokers is not to be expected before around 2 years after quitting.

Because of the time lag between mutation, and disease detection.

Most of the increased risk is avoided by those who stop smoking before middle age

A systematic review found that smoking cessation was associated with a reduction in the risk of all the major histologic types of lung cancer.

the risk for adenocarcinoma and large cell carcinoma fell off less rapidly than for small cell lung cancer and squamous cell carcinoma.

Cancer typeDisease burden from smoking, additional risk factors, and health benefits from cessation

Esophageal cancer

Second biggest cause of (YLL) from smoking among men (101,100 YLL), and the third amongwomen (25,000 YLL)

Oral cancerThird biggest cause of years of life lost Among men and the fifth among women Strong interaction between alcohol and smoking risk remained elevated compared with never smokers up to 20 years after cessation

Pancreatic cancer

Second biggest cause of smoking-related years of life lost among women There is good evidence of risk reduction following cessation The risk is likely to remain elevated for at least 15 years aftercessation.

evidence of reduced risk for ex-smokers compared with current smokers for squamous cell esophageal cancer and an increased risk was probably maintained for at least 20 years risk among ex-smokers was still twice the risk of never smokers after 10

Urinary tract cancer

There is good evidence of reduced risk among former the risk remained elevated for at least 25 years after cessation.

Cervical cancer

Following cessation, the relative risk returned rapidly to the level of never smokers.

Stomach cancer

Smoking has recently been found to be causally associated with stomach cancer Reduced relative risk compared with persistent smokers but no evidence for non smoker

Laryngeal cancer

Rapid reduction in risk (about 60% at 10 to 15 years compared with smokers), and continuing to fall, although an elevated risk remains compared with never smokers for at least 20 years

Myeloid leukemia

No enough evidence

smoking was associated with pulmonary complications during and following surgery

poorer wound healing

increased complications from radiation therapy

Other studies have associated smoking cessation with increased survival times in breast cancer and non-small cell lung cancer

Smoking operates at different stages in the development of coronary heart disease (CHD):

• reduces the ability of the blood to carry oxygen

• causes progressive atherosclerosis • endothelial injury • thrombotic processes

acute infarction

The evidence is less good than for cardiovascular disease .

The RR decreases with cessation and may reach that of never smokers following 5 to 10 years of abstinence,

depends on past smoking habits, with light smokers (< 20 cigarettes/day) reaching the risk of never smokers within 5 years, whereas heavier smokers may never reach it.

Smoking is the dominant risk factor for (PAD).

RR is slower than for cerebrovascular and CHD, with elevated risk observed even after 20 years.

smoking increased graft failure 3.09-fold in people with PAD who were undergoing arterial reconstructive surgery in the lower extremities

The strongest evidence for benefit is in people with mild COPD.

One RCT, the Lung Health Study, which included people with mild to moderate COPD, found :

an increase in FEV1 in the first year following smoking cessation.

Is a significant health risk for nonsmokers, especially those with pre-existing respiratory and cardiac conditions.

Is now a recognized carcinogen . containing over 50 harmful chemicals, such as :• Formaldehyde• benzene• vinyl chloride• arsenic• ammonia • hydrogen cyanide.

Concentrations of many harmful chemicals are higher in secondhand smoke than in that inhaled by smokers.

Found to be immediately detrimental to the cardiovascular system.

There is a prothrombotic effect with increased platelet stickiness

decreased coronary flow reserves Reduced heart rate variability.

Pooled evidence has indicated a causal relationship between secondhand smoke and both lung cancer and CHD.

Nonsmokers exposed to secondhand smoke at home or at work have about :

• 25% to 30% increased risk of heart disease • 20% to 30% increased risk of lung cancer.

Meta-analysis found that :

• RR increased on average by 24%, with people in the highest workplace exposure categories being twice as likely to develop lung cancer compared with nonexposed people .

Infants and young children are considered especially vulnerable .

Maternal exposure during pregnancy is associated with

• Small decrease in birth weight • Persistent adverse effects on lung function

throughout childhood.

Parental smoke is linked to ever having asthma,

exposure in children has been associated with increased risk for

Sudden infant death syndrome (SIDS) Acute respiratory infections Ear problems Increased severity of asthma.

The Surgeon General has concluded that there is no safe level for secondhand smoke Exposure .

Mechanical ventilation or separation of smokers does not fully eliminate the risk.

Air cleaning systems leave behind small particles.

Heating and cooling systems may distribute smoke throughout a building.

Smoking is the biggest preventable cause of premature mortality

Faris Awadallah AlRehaili

QUITTING PLANQUITTING PLAN

Support group vs Self monitoring Cold turkey vs Nicotine fading Use of medications vs Non use of

medication Set a quitting day

QUIT DAYQUIT DAY Sitting the quit after 7 to 14 days. Quitting on Saturday vs Quitting

Wednesday. Mark the date on your calendar. Be determined to quit on that day. Don’t quit before your Quit Day.

PREPARE FOR YOUR QUIT PREPARE FOR YOUR QUIT DAYDAY stop smoking relating to external and

internal triggers wait 10-15 minutes after the trigger is done. Be consistent. Don’t try to quit smoking or even cut down

yet.

AT THE QUIT DAYAT THE QUIT DAY Get rid of all cigarettes, ashtrays, lighters, and

matches. Have creative alternatives available, such as : Using “meswak” Sugarless gum Sugarless candy A ball to squeeze Rubber bands Tell a lot of people that you’ve quit smoking.

AFTER QUIT DAYAFTER QUIT DAY Irritability, Fatigue, Insomnia, Cough, Dry throat,

Nasal drip, Dizziness, Constipation, Gas, Hunger. most symptoms pass within two to four weeks.Craving for a cigarette.1-Urges only last a few minutes.2-Find out your personal reason and remembering

them when things get a little tough3-Do something to take your mind off smoking.4-Don’t ever take a cigarette from your friend not

even a puff.

Your Role as a FriendYour Role as a Friend

1) Don’t nag, insult, or try to shame the smoker into quitting.

2) Let the smoker know that he is valued as a person.

3) Listen non-judgmentally, Try to see the problem through the smokers’ eyes.

4) Praise the smoker for even the smallest efforts to quit.

Saad Ibraheem AlShammeri

بالحكم تعريفه يتم للعيادة المراجع حضور عندوالنفسية الصحية التدخين وبأخطار للتدخين الشرعي

خالل ومن االجتماعي المشرف مع جلسة خالل منو المعروضات بعض على يحتوي الذي المعرض

المجسمات . -Then the phusician should take the following:-1-Body weight and height2-CO level1-2 ??(normal)3-7??(mild smoking)8-22(severe smoking)- Peak flow meter

By : Yaser Yousef Bakhsh

Pharmacological treatment .

Non pharmacological treatment ( behavioral therapy ).

1. Nicotine based therapy2. Non nicotine based therapy

Both nicotine and non nicotine based therapy can increase the chances of successful smoking cessation.

Nicotine replacement therapy (NRT) : are available as transdermal patch, gum, nasal spray, inhaler, or iozenge.

Reduces the withdrawal symptoms associated with smoking cessation such as anger, anxiety, craving, difficulty concentrating, hunger, impatience or restlessness.

There are two recent high-quality systematic reviews found all forms of NRT to be effective.

In this study observed that the main factor determining the effectiveness of NRT was the level of the nicotine dependence.

Anther study found little good evidence that NRT was effective for people who smoke fewer than 10-15 cigarettes daily . An additional cohort study found that nicotine patches were more effective in achieving long term cessation (52 weeks) in smoker with moderate dependence compared with those with mild to high dependence.

The review found on evidence that one form of NRT is preferable.

Anther study found that positive predictors for the patch were different compared with the nasal spray : low to moderate dependency smokers with white ancestry and a BMI less than 30 kg\m² were more successful with the patch where as highly dependent obese people from a nonwhite background had higher cessation rates with the spray.

Another trail compared four different formats of NRT and found that women were more successful with inhaler compared with gum and men vice versa .

formsOver-the counter

Prescription only

Dose*Side effects

gumyes2mg if < 25 cigarette per day4 mg if ≥ 25 cigarette per day•1 every 1-2 hours for 6 week or 1 every 2-4 hours for 7-9 weeks or 1 every 4-8 hours for 10-12 weeks

Bad test, mouth irritation, jaw pain, orodental problem, GI disturbances, cough

patchyes•>10 cigarette per day: 21mg per day for4-6 weeks or 14mg for 2 weeks or 7mg for 2 weeks•≤10 cigarette\day 14mg \day for 6 weeks or 7mg\day for 2 weeks

Skin irritation, or sleep disturbances.

formsOver-the counter

Prescription only

Dose*Side effect

lozenge

yes2mg if smokes 1st cigarette>30 min.4mg if smokes 1st cigarette within 30 min.1 every 1-2H for 6W, 1 every 2-4H for 7-9W, 1 every 4-8H for 10-12 W

Mouth irritation, bad taste, nausea, dyspepsia, hiccups

Nasal spray

yes1or2 doses\H for 6-8W but at least 8 doses \day.Gradually reduce over 9-14W.

Nasal/sinus irritation, runny nose

Oral inhaler

yesOne-10mg cartridge deliver 4mg nicotine.6-16 cartridge\day for 1-12W.Gradually reduce over next 6-12W

Throat irritation, cough, oral burning, dyspepsia

*dosing in this table is based on manufacturers’ recommendations.

Side effects of NRT include local irritation depends on the route of administration.

NRT is generally safe in patients with stable cardiovascular disease.

Patient preference, cost, and side effect may be consideration when choosing NRT.

1. Antidepressants .

2. Nicotine partial receptor agonists .

3. Other drug therapy .

1. Antidepressants: such as Bupropion is a selective

serotonin\norepinephrine uptake inhibitor(SSNRI)

Nortriptyline is a tricyclic antidepressant(TCA)

But anther antidepressant like SSRI and MAO inhibitor have not been shown to help smoking cessation.

Mechanism of action :

1. Improving depressive symptoms precipitated by quitting smoking.

2.Substituting for possible antidepressant effects of nicotine.

3. Independent neurologic effects such as nicotine receptor antagonist.

It decreases depressive symptoms in highly nicotine dependent smokers, but symptoms rebound when bupropion is discontinued.

Extended therapy with bupropion to prevent relapse has not been found to be beneficial.

Bupropion has been shown to be effective in in people with or without depression and in combination with different types of behavioral support.

A recent trail has shown it to be effective and safe in people with acute cardiovascular disease.

bupropion and nortriptyline appear to be about equally efficacious with NRT

One small trail found that bupropion was associated with higher smoking cessation rate at 6 months compared with nortriptyline or placebo when each was added to intensive counseling therapy.

One randomized control trail found that risk factor for relapse in people treated with bupropion and counseling were younger age, female sex, high levels of nicotine dependence shorter previous quit attempts, previous use of NRT and self reported depression.

2. Nicotine partial receptor agonists: such as Varenicline Cytistine : is the natural chemical from

which varenicline was developed, so it like varencline but has a low price, is less well studies but may also aid smoking cessation .

There have been no quality trails about a third partial nicotine agonist , (lobeline).

Varenicline increases smoking cessation about 3 fold at 1 year compared with placebo.

A systematic review found that compared with bupropion, varenicline increase the odds of smoking cessation about 1,7 fold at 1 year.

drugsFDA-approved

doseSide effects

BupropionyesSet target quit data for during 2nd week of treatment150mg ×3 days, then 150mg twice daily, continue treatment for 7-12W

Dry mouth, sedation, seizure (1\1000) rare

nortriptylineFrom 75-100mg daily for 6-12 weeksSedation, constipation, urinary retention, risk of arrhythmia

vareniclineyesSet target quit data for 1 week after starting treatment0.5mg once daily for 3 days then twice daily for 4-7D, increase to 1mg twice daily from day8 through end of 12 weeks

Nausea, sleep disturbances, headache

3. Other drug therapies: Clonidine a centrally acting

antihypertensive agent, has been studied mostly in conjunction with behavioral counseling can increase smoking cessation 2-fold,but had side effect especially dry mouth and sedation which limit its use.

Tapering of dosing at the end of therapy is recommended to avoid withdrawal effect of clonidine.

Silver acetate gum, lozenge or spray:

causes unpleasant taste when conbined with cigarette.

Limited data don’t support a role of it, possibly because of reportedly poor compliance.

Combination NRT:There is weak evidence that combination

NRT may be more effective than single forms62.

Combining NRT with other drug treatments:There is no good evidence about combining

NRT with varenicline, anxiolytics or clonidine.

Two small studies suggest that adding mecamylamine(nicotine receptor antagonist) to NRT may superior to NRT alone.

Adding NRT to nondrug therapy:

Although the absolute chances of quitting increase when NRT is used in conjunction with additional support.

One trail showed that NRT plus physician training improved quit rates over physiciant training alone.

Nicotine conjugate vaccine:

A vaccine currently in development aims to induce nicotine-specific antibodies in order to prevent nicotine’s passage into the brain.

Date

CASES CASES

46 year-old gentleman with a persistent right lower lobe pulmonary mass after a successfully treated cavitary pneumonia 5 months ago. At the time of presentation he was clinically asymptomatic. The patient worked in the hospital and smoked one pack of cigarettes a day. He recently quit.

A chest CT scan revealed a right lower lobe lung mass and multiple small cavitary nodules.

What is the most likly diagnosis ? PRIMARY ADENOCARCINOMA OF LUNG

35 old teacher came up to your clinic for diabetes follow up .He told you that he is getting weak last 2 month and he has shortness of breath in minimal activity , also he complained of sleep disturbance, and insomnia . He smokes about 1 pack/day for 18 years and he seems to be upset about his habit .He is asthmatic and his asthma exacerbate with seasons .

Would you prescribe for him broncodilator ? Would you refill his diabetic medication ? The patient has good knowledge about the

risk of smoking , would you offer him more information ?

Would you take advantage of his symptoms (shortness of breath and and sleep disturbance ) and relate that to years of smoking ?

Would you prescribe for him nicotine patches or nicotine gums ?

Would you suggest for him to find an alternative activity instead of smoking ?

What else will you do ?

A 54 years old male present to your clinic with the complaint of increased sputum production ,chronic cough ,and shortness of breath for the last several months , he has smoked two packs of cigarettes a day for the last 20 years .

Whats your most likely diagnosis ? COPD Whats is your confirmatory test ? spirometery , ratio of <0.7

Brunnhuber.K, Cumming.K.M, Feit.S, et al, putting evidence into practice smoking cessation:2007 BMJ group. Mannino.D.M. cigarette smoking and other risk factors for lung cancer; 2011 UptoDate. Rubenfire.M, Jackson.E . Cardiovascular risk of smoking and benefits of smoking cessation;2010,UpToDate. Etter J-F, Stapleton JA. Nicotine replacement therapy for long-term smoking cessation: a meta-analysis. Tob

Control 2006;15:280–85. Yudkin PL, Jones L, Lancaster T, et al. Which smokers are helped to give up smoking using transdermal nicotine

patches? Results from a randomized, double-blind, placebo-controlled trial. Br J Gen Pract 1996;46:145–148. Silagy C, Lancaster T, Stead L, et al. Nicotine replacement therapy for smoking cessation (Cochrane Review) In:

The Cochrane Library, ssue 3, 2004. Chichester, UK: John Wiley &Sons Ltd. Search date: 2004; primary source the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Express, MEDLINE, EMBASE, PsycLIT/PsycINFO, Science Citation index.

Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation (Cochrane Review)In: The Cochrane Library, Issue 1, 2007. Chichester,UK: John Wiley & Sons Ltd. Search date:2006; primary source Tobacco Addiction Group’s specialised register, reference lists of identified studies, recent reviews of nonnicotine pharmacotherapy and abstracts from the meetings of the Society for Research on Nicotine and Tobacco, MEDLINE, EMBASE,contact with experts and the GlaxoSmithKline Clinical Trials Register (http:ctr.glaxowellcome-.co.uk).

West R, Hajek P, Nilsson F, et al. Individual differences in preferences for and responses to four nicotine replacement products. Psychopharmacology(Berl) 2001;153(2):225–230.

Rigotti NA, Thorndike AN, Regan S, et al.Bupropion for smokers hospitalized for acute cardiovascular disease. Am J Med–

Lerman C, Niaura R, Collins BN, et al. Effect of bupropion on depression symptoms in a smoking cessation clinical trial. Psychol Addict Behav 2004;18:362–366.

Haggstram FM, Chatkin JM, Sussenbach-Vaz E,et al. A controlled trial of nortriptyline,sustained-release bupropion and placebo forsmoking cessation: preliminary results. Pulmonary Pharmacol Ther 2006;19(3):205–209.

Hurt RD, Wolter TD, Rigotti N, et al. Bupropion for pharmacologic relapse: predictors of outcome.Addict Behav 2002;27(4):493–507.

References:References: