SMOKING CESSATION

Laila MahzariSara AlajmiBushra AlenaziWeam NasserFatimah Alduheem

Objectives

• Introduction.• Chemical components in cigarettes.• The negative effects of smoking.• Benefits of Smoking Cessation.• Electronic Cigarettes: Human Health Effects.• Enhanced Motivational Interviewing Versus Brief

Advice For Adolescent Smoking Cessation: Results From A Randomized Clinical Trial.

• Nicotine Replacement Therapy.• A Randomized Trial of Nicotine-Replacement Therapy

Patches in Pregnancy.• Zyban for smoking cessation in a general: the

response to an invitation to make a quit attempt.• Perceived barriers to smoking cessation in selected

vulnerable groups: a systematic review of the qualitative and quantitative literature.

• Barriers and motivators to gaining access to smoking cessation services amongst deprived smokers.

• Conclusion

INTRODUCTIONLaila Mahzari

Introduction• Cigarette smoking is one of the major preventable causes

of morbidity and mortality all over the world. • According to World Health Organization (WHO, 2008)

Tobacco is the second major cause of death. It is currently responsible for the death of 1 in 10 adults.

Cont.

• In 2005, tobacco caused 5.4 million deaths which was 1 in every 6 seconds.

• It is the major risk factor for the development of chronic

obstructive pulmonary disease (COPD), lung cancer and contributes to risk for heart disease and many other conditions.

Cont.• There are more than 15 billion cigarettes smoked a day

around the world .(World Health Organization; U.S. Centers for Disease Control and Prevention; Action on Smoking and Health (ASH)).

• Smoking is the main cause of behind the death of 13,544 in Saudi Arabia, according to statistics published by the Saudi Charitable Society to Combat Smoking on its website (Ghafour, 2008).

Cont.• The cigarette imports in the country were SR1.7 billion in

2005 and the economic losses caused by smoking were SR25 billion in the five years from 2005 to 2010.

• The majority of Saudi smokers who took part in a recent survey said they started practicing the damaging habit as a result of the influence of friends.

• Some participants (8.4 percent) said it was the family impression that made them smokers while 5.9 percent blamed work pressure for smoking.

Cont.• The total population of the Kingdom is 26.5 million

according to a July 2012 estimate by Central Intelligence Agency (CIA), US. It is estimated that about a quarter of Saudi Arabia's residents smoke.

• Smokers in Saudi Arabia spend more than SR5 billion to buy some 40,000 tons of tobacco yearly, not to mention other losses related to the high cost of the treatment of serious diseases associated with smoking (Fakeeh, 2011).

• Chemical components in cigarettes Because the nicotine in tobacco is addictive, quitting smoking can be challenging.

The negative effects of tobacco and smoking are :

Eyes Macular degenerationHair Hair lossSkin Aging, wrinkles, wound infectionBrain StrokeMouth and pharynx

Cancer, gum disease

Lungs Cancer, chronic obstructive pulmonary disease (emphysema and chronic bronchitis), pneumonia, asthma

Heart Coronary artery disease, raised blood pressure

Cont.

Stomach Cancer, ulcer

Pancreas Cancer, increase blood glucose levels and less control over blood glucose levels

Bladder CancerWomen Cervical cancer, early menopause, irregular and

painful periods, infertilityMen ImpotenceArteries Peripheral vascular diseaseBone Osteoporosis

Cont.• Smoking during pregnancy Increased risk of:

• miscarriage• premature birth• low birth weight infant

• Effect of tobacco smoke on children Increases the risk of:

• respiratory infections

• middle ear infections

• meningococcal infections

• asthma.

Health benefits of quitting12 hours Blood levels of carbon monoxide are significantly

decreased5 days Improvements in the sense of taste and smell6 weeks Risk of wound infection after surgery substantially

reduced3 months Lung function is improving as cilia recover1 year Risk of coronary heart disease is halved after one year

compared to continuing smokers10 years Risk of lung cancer is halved and continues to decline15 years All cause mortality falls to the same level as for those

who have never smoked

Electronic Cigarettes: Human Health EffectsMay 2014 Sara Alajmi

• Methods:Systematic literature searches were conducted through September 2013 to identify research related to e-cigarettes and health effects. Five reference databases (Web of Knowledge, PubMed, SciFinder, Embase and EBSCOhost) 

• e-cigarette components.

Physiological effects observed in clinical studies:• mouth and throat irritation and dry cough at initial use.• no change in heart rate, carbon monoxide (CO) level, or plasma

nicotine level.• increase respiratory flow resistance similar to cigarette use.• no change in complete blood count (CBC) indices.

• Exposure risks for non-users:react with ambient nitrous acid to produce TSNAs, leading to inhalation, ingestion, or dermal exposure to carcinogens.

• Potential for reduced harm or cigarette smoking cessation.

• Marketing information frequently includes a stated or implied claim that using e-cigarettes will help smokers quit or reduce cigarette use. Supporting data, however, are quite limited. small studies have demonstrated short-term reduction in cigarette smoking while using e-cigarettes.

These 81 respondents included 72 daily users of ecigarettes, one non-daily user and eight former users .

• Conclusions• e-cigarettes have potential advantages over traditional

cigarettes, there are many deficiencies in the available data.

• There are not adequate data to support the safety of long-term use of electronic cigarettes at this time.

• No e-cigarette has been approved by FDA as a cessation aid.

Enhanced Motivational Interviewing Versus Brief Advice For Adolescent Smoking Cessation: Results From A Randomized Clinical TrialPublished in 2012 

Methods

• Adolescent cigarette smokers 14–18 years old (n = 162)

• 85 males • 77 females• smoke at least once per week for the past month.• MI = 79 BA= 83• Patients with recent traumatic injury (in medical settings)

were excluded

MI• therapeutic style:

 1) establishing rapport 2) exploring pros and cons of smoking and quitting. 3) delivery of computer-generated personalized assessment feedback.4) imagining the future with and without smoking.5) reviewing a menu of change options and .developing a change plan.6) enhancing self-efficacy for change.

• Telephone boosters.discussion was designed to reinforce progress toward goals in MI ,  In BA, the 5-minute discussion reiterated strong directive advice to quit smoking and maintain abstinence .

• Parent intervention:

in MI focused on increasing parent support for the adolescent’s goals for changing smokingParents in both conditions were mailed informational materials on helping adolescents quit smoking.

Finally• There is a need for efficacious interventions for

adolescent smokers. In this trial, MI modestly reduced smoking rates (average cigarettes per day) in the short-term compared to BA.

• MI may provide an efficacious first step toward smoking cessation. An important direction for future intervention development research is how best to capitalize on these proximal effects to lead to longer-term abstinence for adolescent smokers.

NICOTINE REPLACEMENT THERAPY

Bushra Alenazi

How It Works?• It helps to reduce nicotine withdrawal and craving (by

supplying the body with nicotine). • It contains about one-third to one-half the amount of

nicotine found in most cigarettes.• Nicotine replacement therapy is safe when used

properly. • Nicotine by itself is not nearly as harmful as smoking.• Tars, carbon monoxide, and other toxic chemicals in

tobacco cause harmful effects, not the nicotine

Types of NRT• The US Food and Drug Administration (FDA) has

approved 5 forms of nicotine replacement therapy:

Studies

Adverse events associated with nicotine replacement therapy (NRT) for smoking cessation.

A systematic review and meta-analysis of one hundred and twenty studies involving 177,390 individuals

Edward J Mills1*, Ping Wu2, Ian Lockhart3, Kumanan Wilson4, Jon O Ebbert5 Published in 2010

METHOD

10 electronic databases from inception to November 2009

Ninety-two RCTs involving 32,185 participants

28 observational studies involving 145, 205 participants were identified.

RESULTpooled RCT evidence of varying NRT formulations found :• increased risk of:

heart palpitations and chest pains

nausea and vomiting gastrointestinal complaints

insomnia

Cont: Result• Pooled evidence specific to the NRT:

patch found an increase in skin irritations

Orally administered NRT was associated with mouth and throat soreness , mouth

ulcers ; hiccoughs and coughing

Cont: Result

• There was no statistically significant increase in anxiety or depressive symptoms associated with NRT use.

Discussion• Although NRT was associated with an increased risk of heart

palpitations, the review did not observe an increased incident of heart attack or death.

• The most serious adverse event reported in both RCTs and observational studies were heart palpitations and chest pains.

• Psychological adverse events, particularly suicidal ideation, are a major concern in patients initiating smoking cessation. They found only one large retrospective observational study that discussed this topic and reported no significant difference in fatal and non-fatal self-harm associated with NRT compared to other frequently used pharmacotherapies, bupropion or varenicline.

conclusion• This review demonstrates that NRT is associated with adverse

effects that may be discomforting for the patient but are not life-threatening.

• Clinicians should inform patients of potential side effects which are associated with the use of NRT for the treatment of tobacco dependence.

Second study• A Randomized Trial of Nicotine-Replacement Therapy

Patches in Pregnancy• march 1, 2012

METHODSThey took participants from 7 hospitals in England who where: 16 to 50 years of age with pregnancies of 12 to 24 weeks’ gestation smoked 5 or more cigarettes per day.

Participants received:1- behavioral cessation support2- and they randomly assigned to 8 weeks of treatment :

With active nicotine patches (15 mg per 16 hours) or matched placebo patches.

Cont: METHOD• Abstinence from the date of smoking cessation until

delivery:Validated by measurement of exhaled carbon monoxide or salivary cotinine.

• Safety was assessed by monitoring for adverse pregnancy and birth outcomes.

Result • Of 1050 participants, 521 were randomly assigned to

nicotine-replacement therapy and 529 to placebo:

• There was No significant difference in the rate of abstinence from the quit date until delivery between the nicotine-replacement and placebo groups.

conclusion

Adding a nicotine patch (15 mg per 16 hours) to behavioral cessation support for women who smoked during pregnancy did not significantly increase the rate of abstinence from smoking until delivery or the risk of adverse pregnancy or birth outcomes.

Weam Nasser

• The objective of this study to assess the feasibility and

success of Zyban as part of smoking cessation programme within UK general practice.

Sample: smokersNever used ZybanHad participated in previous NRT trial (PATCH 2 study in 2000 )

N= 479

Continuing smokers from the Patch 2 study, who had

never used Zyban

(n=479)

Excluded (n=240)- Previous use of Zyban- -risk of seizures- -clinical contra-

indications- Other medications- Light or x-smokers- Moved away- Died- Refused contact- Other

INVITED (n=239)

Refused (n=65)No Reply (n=40)

Accepted (n=134)

Failed to contact their GP

Made and kept GP appointment (n=79)

Eligible to enter the study (n=74)

Met the nurse and set quitdate (n-63)

Made a quit attempt

(n=54)

Figure 1. Flow diagram of Participation.

1. The participants discuss the study with their

GP

2. The GP then

prescription for

Zyban (60 × 150 mg tablets)

3. the study

schedule followed was 150 mg once daily for six days

4. increasin

g to twice daily (total 300

mg/day) from day

7

5. If tolerated

, making the quit

attempt

Fagerstrom test

Hospital Anxiety and Depression Scale (HADS)

the Eysenck Personality questionnaire.

Testing scales and questionna

ires

Smoking status

(cotinine)

@8-12-26-52 weeks

They were Geno-typed(SNPs)

3×10

marked difference between men and womenP<0.05

successful quitters at six and twelve months in PATCH 3 showed a trend to lower mean nicotine dependency score (11.8 and 12.2 respectively) than those who made an unsuccessful quit attempt (14.4).

The most notable positive finding was that women fared less well than men,

which is a not uncommon finding and suggests that additional ways to help

female smokers overcome the problems they face may be

warranted.

Too few subjects!!

Weam Nasser

between July 2011 and July 2013Randomized double blinded, placebo control trialDone @ 61 center In 10 countries(Australia, Canada, Czech Republic, Egypt, Germany, Japan, Mexico, Taiwan, United Kingdom, and United States)

Participants were recruited through advertising.

24 weeks: 12 weeks reduction 12 weeks of abstinence

28 weeks: follow-up

Eligibility

- Age >=18- Smoke around >=10 cigarettes/day- No abstinence period >3months/past year- Exhaled CO > 10ppm- Not willing or able to quit smoking the next month,But willing to reduce smoking the next 3 months

Exclusion:history of a suicide attempt or suicidal behaviourmajor depressive Psychosispanic disorderposttraumatic stress disorderor schizophreniasevere chronic obstructive pulmonary diseasealcohol or substance abusesignificant cardiovascular or cerebrovascular diseasepregnancy, lactating

Of 1747 potentially eligible participants screened, 1510 (86%) was accepted

Method Week 1

Week 4: 50%Week 6

Week 8: 75%

Week 12: Quitting

Counselling training was provided-Advices on reduction techniques-focus on problem solving -skills training -highlight successes.

Vareneciline or placebo at dose of 0.5mg once/day

for 3 days

0.5mg twice/day from day 4-7 1.0mg twice/day

• continuous abstinence rate (CAR) during the last 10 weeks of treatment (weeks 15-24)

• CARs during weeks 21 through 24

• during weeks 21 through 52.

Enrollment

Results

Time Vareneciline placebo4 Weeks 50% 47.1% 31.1% 8 Weeks 75% 26.3% 15.1%

Conclusion• Among cigarette smokers not willing or able to quit within

the next month, but willing to reduce cigarette consumption and make a quit attempt at 3 months, use of Vareneciline for 24 weeks compared with placebo significantly :

increased smoking cessation rates at the end of treatment

PERCEIVED BARRIERS TO SMOKING CESSATION IN SELECTED VULNERABLE GROUPS: A SYSTEMATIC REVIEW OF THE QUALITATIVE AND QUANTITATIVE LITERATURE Received 25 August 2014 Accepted 20 November 2014 Published 22 December 2014

Fatimah Alduheem

DesignA systematic review was carried out to identify the perceived barriers to smoking cessation within six vulnerable groups.

ObjectivesTo identify barriers that are common and unique to six selected vulnerable groups: low socioeconomic status; Indigenous; mental illness and substance abuse; homeless; prisoners; and at-risk youth.

AimsA.Identify barriers that are common across all vulnerable

groups included in the review.B.Identify barriers that may be unique to specific groups.

The results of the review will be used to develop a practical model to help understand the barriers to quitting among vulnerable groups and to aid smoking cessation intervention development.

Methods• Study design.• Databases and search.• Inclusion and exclusion criteria.• Risk of bias in individual studies.

Discussion• Main barriers identified across all vulnerable groups :1.Stress management.2.Lack of support to quit from health professionals

and other service providers.3.High prevalence and acceptability of smoking.

Barriers specific to certain groups• Indigenous groups : Indigenous groups identified unique stressors linked to smoking including racism and historical factors; cultural practices including ceremonial use of tobacco and cultural values that promote sharing.• Prisoners : Prisoners identified unique stressors within their living conditions that contributed to their smoking including social isolation, anxiety regarding legal matters and transfers to other prisons.• People with a mental illness :Low motivation to quit smoking.

ConclusionVulnerable groups experience common barriers to smoking cessation, in addition to barriers that are unique to specific vulnerable groups. Individual-level, community-level and social network-level interventions are priority areas for future smoking cessation interventions within vulnerable groups.

BARRIERS AND MOTIVATORS TO GAINING ACCESS TO SMOKING CESSATION SERVICES AMONGST DEPRIVED SMOKERS qualitative study

Received: 2 August 2006Accepted: 6 November 2006Published: 6 November 2006

BackgroundSmoking is strongly associated with disadvantage and is an important contributor to inequalities in health. Smoking cessation services have been implemented in the UK targeting disadvantaged smokers, but there is little evidence available on how to design services to attract this priority group.

MethodsWe conducted focus groups with 39 smokers aged 21–75 from the most socio-economically deprived areas of Nottingham UK who had made an unsuccessful attempt to quit within the last year without using smoking cessation services, to identify specific barriers or motivators to gaining access to these services.

DiscussionThe participants in this study were smokers who had previously attempted to quit smoking without formal support, and who lived in extremely deprived areas. Although motivated to quit smoking, they felt that their smoking was intractable and were torn between thinking that only intensive measures would help them to stop but also that all that was really required was willpower. They felt increasingly marginalised by society and government and felt that their addiction was not taken as seriously as addiction to heroin or alcohol. They knew little about the services available to help them, but perceived them to be ineffective and expensive despite evidence to the contrary. Participants stated the need for a wide variety of cessation group timings and locations without being aware that these services already existed.

Results• Barriers to use of existing services related to fear of being judged,

fear of failure, a perceived lack of knowledge about existing services, a perception that available interventions – particularly Nicotine Replacement Therapy – are expensive and ineffective, and negative media publicity about bupropion.

• Participants expressed a preference for a personalised, non-judgemental approach combining counselling with affordable, accessible and effective pharmacological therapies; convenient and flexible timing of service delivery, and the possibility of subsidised complementary therapies.

ConclusionWe conclude that smokers from these deprived areas generally had low awareness of the services available to help them, and misconceptions about their availability and effectiveness. A more personalized approach to promoting services that are non-judgmental, and with free pharmacotherapy and flexible support may encourage more deprived smokers to quit smoking.

Conclusion

Summary • Cigarette smoking is one of the major preventable causes of morbidity and

mortality all over the world.

• The earlier smoking is stopped, the greater the health gain.

• No e-cigarette has been approved by FDA as a cessation aid

• There is a need for efficacious interventions for adolescent smokers

• This review demonstrates that NRT is associated with adverse effects that may be discomforting for the patient but are not life-threatening.

Cont.• Adding a nicotine patch during pregnancy did not significantly increase the

rate of abstinence from smoking until delivery or the risk of adverse pregnancy or birth outcomes.

• Zyban can reduce the nicotine dependency score within a 12 months course.

• Gender and genotype may play a role in smoke cessation, but further studies are needed to ensure that.

• Vareneciline helped in smoke cessation for smokers whose unable to stop within 3 months.

• There are many barriers to quit smoking but with the strong motivation they can quit smoking.