Quit Smoking Programme

Report
MODULE 3
Clinical Practice Guideline Treatment
for Tobacco Use and Dependence
Problem of Tobacco Use




Recent estimate 49.2% of Malaysian male
adults use tobacco.
There is a rising trend of smoking among
adolescent.
Three main disease related to smoking are
heart disease, stroke and cancer.
THEREFORE tobacco cessation are highly
cost-effective health preventive intervention.
Problem of Tobacco Cessation

Clinicians are reluctant to address the
smoking problem because they believe;
1.
2.
3.
4.
Tobacco dependence is a habit and not a
dependent disorder ( chronic relapsing illness)
They have no knowledge and skills to treat
tobacco use and dependence.
Not realizing that brief intervention can increase
the quit rate among smokers.
Pharmacotherapy can only be used with intensive
cessation treatment.
Assessment of Tobacco Use



All patients should be asked if they use
tobacco and should have their tobacco-use
status documented on a regular basis.
Evidence has shown that this significantly
increases rates of clinician intervention.
Guideline in assessing tobacco use.
Brief Clinical Intervention


This intervention only requires 3 minutes of
clinician time.
It has 3 types of intervention addressing




Smokers who willing to quit.
Smokers unwilling to quit.
Smokers recently quit.
A guideline is provided using 5A’s and 5R’s
Brief Interventions -
The 5As
The essential features;
Ask
Advise
Assess
Assist
Arrange
( tanya )
( nasihat )
( nilai )
( bantu )
( atur )
Intensive Clinical Intervention


Evidence shows that more intensive tobacco
dependence treatment is more effective than
brief treatment.
This could be achieved by increasing



The length of individual treatment sessions
The number of treatment sessions
Specialized behavioural therapies.
Pharmacotherapy

In addition to counselling, all smokers should
receive pharmacotherapy if they fulfill the
criteria below:


With scores from Fagerstrom’s questionnaire of
> 4.
Smoking > 10 cigarettes per day.
Pharmacotherapy

Recommended first line agents includes:



Sustained release (SR) buproprion
Nicotine replacement therapies ( NRT, e.g gum,
patch, nasal spray and inhaler )
Recommended second line agents includes


Clonidine
Nortriptyline
Pharmacotherapy

Combination of pharmacotherapies has been
shown to be more efficacious than a single
agent:


2 NRT’s
Bupropion and a NRT
# especially if had failed using a single agent.
Nicotine Replacement therapy
Type of Nicotine
Nicotine Replacement Therapy.
Replacement Therapy.
Aim : Free of smoking within 3 - 6/12
Eliminate urge not withdrawal
symptoms

Nicotine Gum
will help relieve many of the

Nicotine Patch
withdrawal symptoms that a

Nicotine Spray

Nicotine Oral Inhaler
Supply small amounts of nicotine that
smoker may feel when quitting,
Quit smoking completely before
starting to use any nicotine
replacement therapy.
Not for pregnant or lactating women
Nicotine Replacement Therapy
Fagerstrom Number of Level of
Nicotine
Score
cigarette dependency replacement
0–3
< 10
Mild
No
4–5
10 - 25
Moderate
Yes ( 2mg )
6 - 10
> 25
Highly
Yes ( 4mg )
Nicotine Replacement therapy
NICORETTE NICOTINE GUM
Suggestion 1
Weeks
1 through 6
Weeks
7 through 9
Weeks
10 through 12
1 piece every
1 to 2 hours
1 piece every
2 to 4 hours
1 piece every
4 to 8 hours
Do not use more than 24 pieces per day
Nicotine Replacement therapy
NICORETTE NICOTINE GUM
Suggestion 2
Suggestion 3



7 pieces/ day for 12 weeks





1st 6 weeks
7th wk
8th wk
9th wk
10th wk
11th wk
12th wk
: 7 pieces/day
: 6 pieces/day
: 5 pieces/day
: 4 pieces/day
: 3 pieces/day
: 2 pieces/day
: 1 piece/day
Nicotine Replacement therapy
NICOTINE PATCH – Nicotinell TTS
Suggestion 1
Weeks
1-4
5-8
9 – 12
> 20 cig / day
TTS30
( 21mg )
TTS20
( 14mg )
TTS10
( 7mg )
< 20 cig / day
TTS20
( 14mg )
TTS10
( 7mg )
TTS10
( 7mg )
Use 16-hour patch (instead of 24-hour) if experience sleep disturbance
Suggestion 2
NICOTINE PATCHES
Nicotine Replacement therapy
Patch
Nicotine Dose (Daily)
Step Duration
NicoDerm CQ
Step 1
Step 2
Step 3
(24-hours use)
21mg
14mg
7mg
Nicotrol patch
(16-hours use)
15 mg
Heavier smokers
(10+ cigarettes/day)
Step 1 : 6 weeks
Step 2 : 2 weeks
Step 3 : 2 weeks
Lighter smokers
(<10 cigarettes/day)
( Begin at Step 2 )
Step 2 : 6 weeks
Step 3 : 2 weeks
6 weeks
Habitrol
Step 1
Step 2
Step 3
(24-hours use)
21mg
14mg
7mg
Heavier smokers
(20+ cigarettes/day)
3 to 4 weeks each
step
Lighter smokers
(<20 cigarettes/day)
( Begin at Step 2 )
Step 2 : 6 -8 weeks
Step 3 : 3 -4 weeks
Pharmacotherapy
Bupropion hydrocloride SR
( Zyban )
Anti Depressant
Boosts the body’s level of two
“
brain chemical ” - dopamine &
Norepinephrine ; sense of energy
Reduce witdrawal symptoms ; lessens
the “ URGE “
Start before Q day ; set Q day one to
two weeks after starting treatment.
150 mg BD - 7 - 12 weeks
Non- Nicotine
Pill
Pharmacotherapy
BUPROPION Hcl SR
START
MAINTENCE
150mg daily :
150mg b.i.d :
First 3 days
7 – 12 weeks following Q
( begin treatment 2
weeks before Q day )
150mg b.i.d :
Consider 6 months
SIDE EFFECT
Nicotine gum
Insomnia, mouth sore, hiccups
dyspepsia, jaw ache
Nicotine patch
Headache,insomnia,dizziness,anxiety,irritability,
fatique,nightmare,stomach upset,diarrhea and
constipation.
Nicotine inhaler
Mouth or throat irritation, coughing,runny nose,
indigestion,nausea,diarrhea,hiccups.
Nicotine nasal spray
Nasal irritation,watering eyes,sneezing,runny
nose,throatirritation,coughing,nausea and
headache.
Bupropion Hcl
Restlessness,agitation,dizziness,dry mouth,
difficulty sleeping,headache,nausea,vomiting,
constipation,change in weight,tremor
MEDICATION guide
Nicotine Replacement Therapy
Comparison of Nicotine Replacement Products
Gum
(4 mg)
Patch
Availability for purchase. (Prescription medications will require a
visit to your physician.)
Over-thecounter
Over-thecounter
Prescription
Prescription
Flexible dosing (used when you feel you need it, as opposed to on
a schedule)
yes
no
yes
yes
Allows for extinction of sensory/ritual reinforcers (helps to break
the habit side of the addiction)
no
yes
no
no
Speed of onset; T-max (the time until the medication reaches its
full strength in your blood stream. A lower time indicates it can be
used to break a craving situation.)
10 mins
2-12 hrs
5-10 mins
15 mins
Suggested frequency of use (doses per day)
9-20
1
13-20
6-16
Effort required for proper use
high
low
moderate
high
Mimics oral/behavioral aspects of smoking
no
no
no
yes
Primary side effects
mouth/throa
t soreness
topical skin
irritation
nose/throat
irritation; runny
nose
cough; throat
irritation
Characteristic
Nasal Spray
Oral Inhaler
(Adapted from Schmitz J., Henningfield J, Jarvik M, "Pharmacologic Therapies for Nicotine Dependence." In Principles for
Addiction Medicine, 2nd ed., 1998).
The 5R – Motivational Intervention





Relavence – personal relavent
Risks – potential negative consequence; short
and long term, environmental
Rewards – potential benefits
Roadblocks – barriers or impediments
Repetition
Problem encountered





Lack of support for cessation.
Negative mood or depression.
Strong or prolonged withdrawal symptoms.
Weight gain.
Flagging motivation ; feeling deprived
Intensive Practice Relapse
Prevention
PROBLEM ENCOUNTERED
Lack of support for cessation
Negative mood or depression
Strong or prolonged withdrawal
symptoms
Weight gain
Flagging motivation
INTENSIVE PRACTICE RELAPSE
PREVENTION
1.
2.
3.
4.
Rescheduled follow-up
Proactive telephone counseling
Identification of support network
Appropriate referral
1. Counseling
2. Appropriate medication prescription
3. Appropriate referral
1. Extended use of approved pharmacotherapy.
2. In-patient care
1.
2.
3.
4.
Healthy life style modification.
Pharmacotherapy
Appropriate referral
Surgical intervention ?
1. Motivational intervention – the 5R’s
Level 1 Care
Level 2 Care
Walk in / referred client
Walk in clients :
Non alcoholic, non drug
addict
START
FIRST VISIT
Registration
( refer to Borang Saringan )
Assessment of Medical Status *
Smoking history
Fagerstrom score
Assess smoking status
** and motivation
Institute appropriate
treatment ( refer CPG )
NO
Co morbid conditions ?
YES
Refer to appropriate
discipline
Follow up date to
Quit Smoking Clinic
Medical history
Family – Support
history
Physical Examination:
BP, BMI, Pulse, RR,
PEFR
Breath CO level
Oral Examination
Client with
appointment
START
SUBSEQUENT
VISIT
Retrieve client’s record
Assessment of adverse effect,
Compliance,
Withdrawal symptoms,
CO Analyzer,
Lung function test,
Weight
Refer follow up protocol
Special investigation on
request e.g Lipid profile
Continue treatment
Refer treatment protocol
Scaling on 3rd appointment
Follow up date to
Quit Smoking Clinic
Refer when appropriate
- Dietician
- Stress
management
- Counsellor
- Other discipline
THANK YOU
for
A smoke free world

similar documents