Rawatan ,Pemulihan Penagihan nikotin

Oleh: Dr Izani Uzair bin Zubair Ketua Penolong Pengarah(Perubatan) Jabatan Kesihatan Negeri Pulau Pinang

SMOKERS TRAP FOR LIFE

active
Individual

passive preference dependence

experience
regular / irregular

Increasing dissonance
Happy smokers 30% Dissonant smokers, 70%

I want to do something about my smoking

Brief Interventions - The 5A

The essential features; Ask ( tanya ) Advise ( nasihat ) Assess ( nilai ) Assist ( bantu ) Arrange ( atur )

Is smoking an ADDICTION ?

Addiction - criteria :
Psychological

and physical

dependence Withdrawal ( gian ) Compulsive drug use

Is smoking an addiction

A highly controlled or compulsive pattern of drug use Psychoactive or mood altering effects, involved in the pattern of drug taking : mood -altering , anxiety reducing and stimulating effects. Drug functioning as a reinforcer to strengthen behaviour and lead to further drug ingestion.

EPIDIOMIOLOGY

MARKET

Smoking
1,1 bn smokers in the world
47% men 12% women Consumption stable

300 m in developed countries

42% men 24% women Consumption declining

A heterogeneous market including one third of the population

MARKET

Tobacco causes
3 million deaths per year
I f current smoking patterns persist 500 million people presently alive (9% of the worlds population) will be killed by tobacco
250 million deaths from children who will start smoking

250 million deaths from existing smokers

Smoking is the single largest preventable cause of death and disease

Smoking Statistics (NHMS)

1986 1996

Overall Male Female Urban Rural Malay Chinese Indian Others

21.5% 40.9% 4.1% 19.2% 22.7% 23.7% 17.7% 15.2% 32.8%

24.8% 49.2% 3.5% 21.7% 28.6% 27.9% 19.2% 16.2% 32.4%

Number of smokers Estimates

2000 2025
30 m 7.2m (24%) 22.8m (76%) 30% 10% 20% 4.6 m

Population Population ( < 15 years) Population ( > 15 years) Prev. adult smokers : Male smokers Female smokers Overall adult prev.

22 m 7.5m (34%) 14.5m (66%) 49% 4% 25% 3.6 m

Number of adult smokers

Youth smoking statistics

People age 18 years and <

Prevalence 1996 16.9% (male : 30.7%, female : 4.8%) 1999 18.2% (males : 29%, females : 8%)
Daily, 45 - 50 youths start to take up smoking

SURVEY IN SCHOOLS MALAYSIA GLOBAL YOUTH TOBACCO SURVEY 2003

5 principal causes of all medically certified deaths (Govt. Hosp.1998)

1. Heart diseases & diseases of pulmonary circulation 14.09% 2. Septicaemia 12.54% 3. External causes 9.67% 4. Cerebrovascular diseases 9.36% 5. Malignant Neoplasm 8.91%

HEART DISEASES
More than 100 000 people suffer as a result of heart conditions in year 1998 with more than 12,000 deaths ( inclusive of private hospital )

Total Admission and Death of Heart Conditions CVD in Govt Hospital Malaysia (1988 - 1998)
120,000 100,000 80,000 60,000 40,000 20,000 0

19 88

19 89

19 90

19 91

19 92

19 93

19 94

19 95

19 96

19 97

Admission

Deaths

19 98

Withdrawal symptoms
Psychic
Craving/missing cigarettes Dysphoria Nervousness, tenseness, anxiety

Vivid dreaming
Sociability Restlessness Impatience Insomnia

Difficulties in concentrating
Irritability, anger, aggressiveness Drowsiness, tiredness, sleepiness

Withdrawal symptoms
Somatic
Sweating Dizziness Blisters/ulcers mouth and throat Obstipation Creeping sensations in or beneath the skin Tremor Hunger/weight gain Disturbed vision

Swelling of joints and pain

Broader use
I want to cope when not allowed to smoke

I want to cut down

I want to quit completely

STRATEGIES
Motivation

QUIT
Cessation
relapse prevention
TOTAL ABSTINENCE

Motivation

CUT DOWN
Reduction

partial
reduction

complete reduction

QUIT
Cessation
relapse prevention
TOTAL ABSTINENCE

Motivation

CONTROL CRAVINGS
Temporary abstinence
partial reduction

CUT DOWN
Reduction

controlled smoking

partial
reduction

complete reduction

QUIT
Cessation
relapse prevention
TOTAL ABSTINENCE

active
Individuality

passive preference

dependence
experience regular / irregular

REGISTRATION

REGISTRATION CARD

BODY MASS INDEX Weight & Height

ASSESSEMENT & CREATING INTEREST

WHEN SMOKERS QUIT..

Within 20 minutes of smoking that last cigarette, the body begins a series of changes

AT 20 MINUTES AFTER QUITTING

Blood pressure decreases Pulse rate drops Body temperature of hands and feet increases

AT 8 HOURS
CO level in blood drops to normal O2 level in blood increases to normal

AT 24 HOURS
Chance of a heart attack decreases

AT 48 HOURS
Ability to smell and taste is enhanced, nerve endings start growing

New clue to why smokers look older

March 22

Theres a new wrinkle in the old question of why smokers faces are prematurely lined. A report in The Lancet medical journal this week suggests smoking switches on a gene involved in destroying collagen, the structural protein that gives skin its elasticity.

ASSOCIATED PRESS

ARSENIC Arsenic boleh menyebabkan bibir BENZOPYRENE anda terbakar dan menyebabkan Bahan ini terdapat di dalam asap nafas anda berbau busuk. METHOPRENE rokok dan merupakan satu bahan kimia

kimia ini digunakan di dalam yangBahan boleh menyebabkan kanser. ACETONE kebanyakan racun serangga khususnya
Bahan kimia ini digunakan kntuk menghapuskan kutu. sebagai LEAD bahan utama untuk membuat

Keracunan atau pendedahan kepada Lead dalam penanggal pewarna kuku. FORMAL DEHYDE satu tempoh masa yang panjang boleh Bahan kimia ini boleh menyebabkan menyebabkan tumbesaran terbantut. Ia kanser, juga
CADMIUM merosakkan paru-paru, kulit dan sistem boleh menyebabkan kerosakan otak.

penghadaman. Ianya seringkali digunakan untuk

kerosakan ginjal, hati dan otak

Bahan kimia ini boleh menyebabkan

PROPYLENE mengawet mayat. GLYCOL

Bahan ini udahkan nikotin menyerap kedalam sistem tubuh khususnya ke otak.

Role of Nicotine
ACTION Release ofan epinephrine from adrenal cortex

Fuses with acetylcholinen in the brain

EFFECT causes fatique & excitement due to excessive release of glucose.

Effect on mood, alertness

Pleasure sensation

Release of dopamine

SHORTNESS OF BREATH

Lung Cancer

SVC Obstruction

Mouth cancer

Bronchietasis

Emphysema

Chronic Obstructive Airways Disease

Peripheral Vascular

Disease

Women 'suffer more from smoking'

November 15, 2000 Web posted at: 6:13 AM EST (1113 GMT)

LONDON, England -Women suffer more from smoking than men because of their generally smaller lungs, scientists say. Women are more vulnerable than men to the breathing problems and other harmful effects of smoking, Norwegian doctors found during two years of study.

BREAST CANCER

CANCER CERVIKS

INFANT cacat

Female smokers has risk of 3X for abortion during pregnancy

abortion

PREMATURE DELIVERY

LOW BIRTH WEIGHT

EXAMINATIONS - PHYSICAL & GENERAL IX

LUNG FUNCTION TEST

LUNG FUNCTION TEST

PULMONARY EXPIRATORY FLOW RATE

FAGERSTROM TEST

Fagerstrms test for nicotine dependence

Questions: 1. How soon after you wake up do you smoke your first cigarette? Answers: Within 5 minutes 6-30 minutes 31-60 minutes After 60 minutes Yes (mark your alternative) 3 2 1 0 1

2. Do you find it difficult to refrain from smoking in places where it is forbidden e.g. in church, at the library, in cinema, etc.? 3. Which cigarette would you hate most to give up? 4. How many cigarettes do you smoke per day? 5. Do you smoke more frequently during the first hours after waking than 6. during the rest of the day? Do you smoke if you are so ill that you are in bed most of the day?
Minimum score 0 Maximum score 10 Average score 4

No
The first one in the morning? All others? 10 or less 11-20 21-30 31 or more Yes No Yes No

0
1 0 0 1 2 3 1 0 1 0

Total

EXAM OF PUPILS

EXAM OF FLEXORS

EXAM OF FOOT BURGERS DISEASE

Chest Xray : COAD

MRI
Smoker
C11 -

Non-smoker
Nicotine

BLOOD PRESSURE

DENTAL EXAMINATION FOR NICOTINE

FITNESS TEST

FITNESS TEST (STAMINA)

SMOKING SUE

GENERAL INFORMATION SPECIFIC TOWARDS SELF & WIFE AND CHILDREN

RISK MALES VS FEMALES

MESEJ HATI

SAVINGS
Expenditure daily 2 box of cig RM 8.00 Nicorette (2mg) 5 tab 0.56 X 5 2.80 Nicorette (4mg) 5 tab 0.68 X 5 3.40

(SAVE RM 150.00 a MONTH RM 1800.00 YEAR RM 18,000.00 10 YEARS

Nicotine Replacement Therapy AS STIPULATED IN CLINICAL PRACTICE GUIDELINES OF MALAYSIA

Benefits

Nicotine

Toxicities

Cognitive Enhancement

Hypothermia

Vigilance/ Antipsychotic
Anxiolysis

Gastrointestinal distress

Emesis

Nicotine
Cerebrovasodilation Neuroprotectio n Analgesia
Fig.7. Benefits and toxicities of (-)-nicotine

Hypertension

Seizures Respiratory Paralysis

Rawatan

farmakologikal

Nicotine replacment therapy NRT GUM (Nicorette Gum)

Flexible dosing to meet individual and situational needs Two strengths: 2mg for low- and mediumand 4mg for high-dependent smokers Some behavioral replacement (oral gratification) Good for relapse prevention

Dosage Guide Allow the smoker to control how much nicotine is used, and when it is used. Nicorette comes in different strengths so it is important to prescribe the correct strength to suit the persons individual smoking pattern.

ALWAYS ENCOURAGE FIRST TIME USER TO CHEW ONE PIECE OF THE NICORETTE GUM IN FRONT OF YOU TO ENSURE THE RIGHT CHEWING TECHNIQUE IS USED.

Dosage Guide Most people use 10-15 pieces of Nicorette gums a day. However, they should not chew more than 60mg (30 pieces of 2mg or 15 pieces of 4mg) in a day Nicorette should be used for at least 3 months before gradually reducing the number of pieces chewed.
ALWAYS ENCOURAGE FIRST TIME USER TO CHEW ONE PIECE OF THE NICORETTE GUM IN FRONT OF YOU TO ENSURE THE RIGHT CHEWING TECHNIQUE IS USED.

Dosage Guide
The level of nicotine dependence based on Fagerstrom Nicotine Dependence Questionnaire (FNDQ) Nicorette 4mg -for heavy, highly dependent smokers (e.g. smoke more than 25 or more cigarettes a day & FNDQ score 6 & above) Nicorette 2mg -for occasional and regular smokers of less than 10 cigarettes or irregular smokers of 10-25 cigarettes a day & FNDQ score below 6.
ALWAYS ENCOURAGE FIRST TIME USER TO CHEW ONE PIECE OF THE NICORETTE GUM IN FRONT OF YOU TO ENSURE THE RIGHT CHEWING TECHNIQUE IS USED.

Dosage Guide
Nicorette gum is not an ordinary gum and should not be chewed in the ordinary way. To make sure the user get the most from their gum, they should follow the special Nicorette chewing technique: (Chew Rest Chew Technique) CHEW Chew Nicorette Gum slowly until taste becomes strong. REST Rests Nicorette Gum between the gum and cheek. CHEW Chew Nicorette Gum again once the taste has faded The process is repeated for approximately 20-30mins.
ALWAYS ENCOURAGE FIRST TIME USER TO CHEW ONE PIECE OF THE NICORETTE GUM IN FRONT OF YOU TO ENSURE THE RIGHT CHEWING TECHNIQUE IS USED.

(Chew Rest Chew Technique)

(Chew Rest Chew Technique)

(Chew Rest Chew Technique)

CHEW Chew Nicorette Gum slowly until taste becomes strong.

(Chew Rest Chew Technique)

REST Rests Nicorette Gum between the gum and cheek.

(Chew Rest Chew Technique)

(Chew Rest Chew Technique)

CHEW Chew Nicorette Gum again once the taste has faded

(Chew Rest Chew Technique)

Park it.(slow down if you start feeling uncomfortable)

(Chew Rest Chew Technique)

After about 1 hour - safely discard it

Treatment is divided into two phases: Phase One - Help smokers to overcome the psychological dependence on Nicotine - Duration of treatment is 3 months. - Smokers are advice to use a fixed amount of Nicorette gums e.g. 8-10 pieces a day for 3 months. Phase Two - Help smokers to overcome the physical dependence on Nicotine. - Duration of treatment is 4-6 weeks. - Smokers are advice to reduce the intake of Nicorette gum gradually. e.g. reduce one piece each week.

Penampal NRT
Dipakai sepanjang hari semasa terjaga. Rawatan sekali dalam sehari. Didapati dlm 3 jenis dos-5mg,10mg dan 15 mg Sesuai untuk tahap nikotin dari tahap sederhana hingga tinggi Mulakan dengan menampal 15mg dan seterusnya ke dos yang lebih rendah.

Nicorette Inhaler
Combines nicotine and behavioral replacement Flexible dosing to meet individual and situational needs

Good for relapse prevention

Nicorette Inhaler
Characteristics

Unique NRT form that provides nicotine saturated in air via oral inhalation As air is inhaled, it is saturated with vaporised nicotine Amount of nicotine released depends on the

volume of air passing through the nicotine impregnated-plug and the temperature One inhalation delivers 13mg at RT, 10 inhalation = 1 puff on a cigarette The only dosage form to address the physical as well as the behavioural dependency

Nicorette Inhaler
Pharmacokinetics

Absorption occurs mainly via the buccal mucosa for

shallow puffing and pulmonary mode for deep inhalation Nicotine release not affected by the inhalation technique; comparable Css T < 15oC - nicotine evaporates more slowly and need to inhale more frequently Inhaler use represents 35% nicotine substitution (within recommended range for replacement therapy)

Nicorette Inhaler
Dosage and administration

The nicotine vapour can be inhaled ad libitum

either by deep inhalation or by shallow puffing Each 10 mg cartridge provides up to 5 mg of nicotine, released over 20 mins of active & continuous puffing 8-2-2 rule
6-12 catridges for 8 weeks, then 3-6 catridges for 2 weeks, then 1-3 catridges for 2 weeks

Nicorette Inhaler
Safety

No serious systemic AE Most common: headache, heartburn,

nausea, mouth and throat irritation

Nicotine; positive effects

Keeps the weight under control Controls alertness Controls feelings Enhance cognitive function Enhance mobility Can provoke euphoria Decrease smoking cravings Blocks or decreases abstinence

DIETITIAN

STRESS MANAGEMENT
OCCUPATIONAL THERAPIST

QUALITY INDICATORS
CRITERIA QUIT 1. URINE TEST NEGATIVE 2. QUIT 6 MONTHS 3. NON DEPENDENCE NRT

REWARDS
Blood Screening(4th week)

ECG(6th week)
CX Ray(8th week)

Scaling & Peridontal Rx (Quit) Medical Examination (quit)

*ACHIEVEMENTS QUIT
1998 -2003(Aug)
60% 50% 50% 40% 30% 20% 10% 0% QUIT(%) 1998 1999 2000 2001 2002 2003(Aug) 22% 33% 43% 53% 53%

*
250 200 150 100 50 0 1998 1999 2000 2001 2002 2003 malay indian chinese

*
98% 100% 80% 60% 40% 20% 0% MALE FEMALE 2%

*
60% 50% 40% 30% 20% 10% 0% <15 years 16 - 20 21-40 41-60 >61 40

THOSE WHO QUIT AND SMOKE AGAIN

FINAL TAKE AWAY MESSAGE

ARTICLES IN LOCAL PAPERS

A smoke free world

TERIMA KASIH THANK YOU