National Guidelines For Tobacco Cessation: Ministry of Health & Family Welfare, Govt of India
National Guidelines For Tobacco Cessation: Ministry of Health & Family Welfare, Govt of India
National Guidelines For Tobacco Cessation: Ministry of Health & Family Welfare, Govt of India
For
TOBACCO CESSATION
6. Relapse prevention 34
° Coping Tips to Stay away from Tobacco
° Type smoker/ Reasons of Tobacco use and tips to
help to quit
7. Self-help intervention for tobacco cessation 37
8. Developing a plan with your client 41
9. Quit tobacco for busy physicians 42
10. Smokeless Tobacco & how to quit it 44
11. Tobacco cessation in dental Clinic 47
12. Tobacco cessation in special situation 51
13. How to start Tobacco cessation services 54
14. Pharmacotherapy 58
15. Other form of therapy 62
16. References 63
17. Appendixes 67
I - Tobacco Cessation Data Collection Form (for
understanding)
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II - Nicotine addiction questionnaire
III - Handouts
IV - TCC Centres
V - Participants of developing guidelines
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1. INTRODUCTION
This learning module is designed to empower clinicians, health educators and counselors
to provide the best behavioral modification strategy / Pharmacotherapy for tobacco
cessations
Tobacco use is leading cause of preventable deaths all over the world. According to WHO
there are 1100 million smokers worldwide, which constitutes one-third of global population
aged 15 years and above. 73% (800 million) of these are in developing countries and 27%
(300 million) in developed countries. Tobacco use is responsible for 3 million deaths
globally every year, two-third of these occur in developed nations. It has been estimated
that without urgent interventions mortality due to tobacco use will rise to 10 million every
year over the next 30-40 years, 70% of which will occur in developing nations.
In view of mortality and morbidity burden due to tobacco use it has become imperative to
take urgent steps to curb the growing menace of tobacco. Decrease in prevalence of
tobacco can be effectively done through two-pronged approach: large scale promotions to
educate the people about the harmful effects of tobacco use and benefits of quitting along
with providing adequate facilities to those who want to quit. Various methods that are
available for quitting should also be publicized as most people who want to quit are not
aware of means available to them. Tobacco cessation measures should be regular part of
healthcare delivery system.
Health care providers are very effective change agents for tobacco using subjects. A
fifteen minute, one-on-one tobacco/cessation session is accepted better by patients than
most other methods of non-pharmaceutical cessation methods. Specific programs
increase tobacco cessation rates, which benefit the subject’s health and are cost effective.
Tobacco use is one of the leading preventable causes of illness and death. The most
powerful predictor of adult tobacco use is smoking during adolescence. Tobacco use is
growing fastest in low-income countries, due to steady population growth coupled with
tobacco industry targeting, ensuring that millions of people become fatally addicted each
year. More than 80% of the world's tobacco-related deaths will be in low- and middle-
income countries by 2030.
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TOBACCO IN INDIA
Tobacco cultivation started about 8000 years back. The Portuguese introduced tobacco in
India during 1566.Tobacco became the valuable commodity and the use spread like a wild
fire.Tobacco is one of the major causes of deaths and disease in India, accounting for
over eight lakh deaths every year. The variety of forms of tobacco use is unique to India.
Apart from the smoked forms that include cigarettes, bidis and cigars, a plethora of
smokeless forms of consumption exist and they account for about 35 percent of the total
tobacco consumption.
The prevalence of tobacco use among the youth has been surveyed by the Global Youth
Tobacco Survey (GYTS) supported by CDC and WHO. GYTS is a tobacco specific survey
to track the prevalence of tobacco use among 13-15 year age group school going
students. GYTS has been conducted in different states of India in the period 2000-2004.
As per this survey, 17.5% of 13-15 year old students are using tobacco in some form.
The prevalence of tobacco use among the Indian Dental Students has also been surveyed
by the GHPS (Global Health Personnel Survey) supported by CDC, Canadian Public
Health Association and WHO. The results of the Global Health Professional Survey done
in India among dental students reported that 9.6% currently smoke cigarettes comprising
14.9% males and 2.4% females respectively.
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3), questions on Tobacco use were asked to individual women and men in the
sample, in the age group 15-49 and 15-54 respectively.
Fact Sheet:
Any Tobacco Use-Prevalence: Tobacco use is more prevalent
57% men among rural population:
10.8% women
35% of rural men smoke
Currently Smoke Cigarette or Bidi cigarettes or bidis compared
32.7% men with 29% of urban men.
1.4% women About 4 out of every 10 men
living in rural areas chew
Currently chew pan masala, gutkha or other tobacco compared too 3 out of
tobacco 10 urban men.
36.5% men One in every 10 women in rural
8.4% women areas chews tobacco.
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TOBACCO HABITS
In India tobacco is used in variety of forms, mainly- smoking, chewing, applying, sucking,
gargling etc. The type of use of tobacco by the individual is dependent on many factors.
Beedi smoking is the most popular form of tobacco smoking followed by cigarette
smoking. Oral use of smokeless tobacco is widely prevalent.
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Smoking Chewing Snuff Application
hookah gutkha
dhumti khaini
chuta paan
cigars
ALL THE TOBACCO PRODUCTS ARE HARMFULL AND ASSOCIATED WITH CANCER
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2. TOBACCO AND HEALTH
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3. NICOTINE ADDICTION
Nicotine acts as an agonist at ganglionic cholinergic receptors inboth the peripheral and
central nervous system and causes the release of a number of neuro-transmittors
including dopanine, noradrenaline, acetylcholine and serotonin.
9
Endocrine system – increased circulating catecholamines such as adrenaline and
noradrenalin and increased cortisol levels
Metabolic system – increased basal metabolic rate
Gastrointestinal system – decreased appetite, nausea
Skeletal muscle – decreased tone.
Nicotine is readily absorbed from the respiratrory tract, buccal mucosa and skin.
There is minimal absorption through the gastrointestinal tract when administered
orally. Cigarettes are highly efecgti ve mechanism for delivering nicotine. Inhaled
nicotine takes about 10-19 seconds to reach the brain when administered through the
pulmonary circulation.
:
The Vicious Cycle of Smoking
A smoker smokes
a cigarette
Noradrenaline
Dopamine Alertness &
‘Good’ feeling energy
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The Vicious Cycle of Smoking
Dopamine, NA
Lights another Cigarette
Relief from Withdrawal
symptoms Withdrawal symptoms
Feels the pleasure again Lack of pleasure
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4. TOBACCO CESSATION SERVICES IN INDIA – A OVERVIEW
Until 2002 there was no formal Tobacco Cessation Services available through our India. The first
formal tobacco cessation clinics in India were set up in 2002, as a joint initiative of the Ministry of
Health and Family Welfare, Government of India and WHO. The initial phase involved the setting up
of tobacco cessation clinics in India and developing models for cessation. Subsequently these
clinics expanded to include training, awareness and advocacy issues and were re-designated as
tobacco cessation centres in 2005. Presently, it is envisaged to make these tobacco cessation
centres nodal to the National Tobacco Control Programme (NTCP).
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7. Telephone Counselling for the defaulters
8. Postal letters to people who do not have access to telephone facility
9. Home visits by social workers as and when required
10. Interaction with quitters during Educational programmes
11. Felicitation of quitters/Distribution of certifificates to quitters
The Ministry of Health and Family Welfare, Government of India has set up a National Tobacco
Control Programme (NTCP), and the experience gathered by the Tobacco Cessation Centres will be
valuable in strengthening to achieve goal of the NTCP.
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5. PROCESS OF CESSATION -- INTERVENTIONAL
STRAGEGIES- the 5A’s
To give individual the best chance at a successful future, it is crucial that subjects quit
their tobacco habit before they develop the diseases. However, it is always better that
people should not start this deadly habit. If started health care providers must attempt to
motivate a change.
The 5A’s are the evidence – based framework for structuring tobacco cessation in health
case setting.
The Five A's (Ask, Advise, Assess, Assist and Arrange) is a five to fifteen minute research
based counseling tool that has proven to be successful.
1. Ask
The Five A's for providers to use as a counseling tool: After the
2. Advise
Behavioral Change Model has been assessed to determine a
3. Assess patient's willingness to quit, the health care provider should apply
the Five A's to assist his/her client in staying tobacco free.
4. Assist
5. Arrange
Step 1 : ASK
ASK - Systematically identify all tobacco users at every visit. It should be put into the
system that every patient/client at every clinic visit, tobacco-use status is queried and
documented.
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Step 2 : ADVISE
Clear Message: "I think it is important for you to quit tobacco now and I can help
you." “Cutting down while you are ill is not enough”.
Strong message: "As your clinician, I need to advise you that quitting tobacco
smoking/smokeless is the most important thing you can do for your health and your
baby's health." (Your health now and in future). The clinic staff and I will help you”.
Personalized message: Tie tobacco use to current health /illness, and /or its social
and economic cost, motivation level/readiness to quit, and /or the impact of
tobacco use on children and others in the house hold.
When you are advising a Clint the frequently asked questions are:
It is always better that while you are advising to quite must tell about benefits of quitting.
.
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BENEFITS OF QUITTING
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Step 3: ASSESS
To be able to assist a client with tobacco cessation you need to be able to assess your
client's willingness to commit to this change. Ask every tobacco user if he/she is willing to
make a quit attempt at this time (eg. within the next 30 days). Here is a flow chart to help
you determine where your client stands.
No: No intervention is
required for this client.
No: Has the client Please encourage
used tobacco continued abstinence.
products in the
past? Yes: Assist with client's
Yes or No tobacco cessation
maintenance in an
attempt to prevent
relapse.
The stages of Readiness to change model is valuable model for assessing a person’s
readiness to change a variety of behaviors. Cessation is explained as process, rather than
a single discrete event and tobacco users through the steps of being ready, quitting and
relapsing, an average of three to four times, before achieving long term success.
Tobacco users will be in different stages of readiness when the health care provider sees
them at different times, so readiness needs to be constantly re-evaluates.
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The stages may be i) Not ready (Pre contemplation) ii) Unsure (Contemplation), iii) Ready
(Preparation) iv) Action, v) Maintenance
CONTEMPLATION
PRECONTEMPLATION
PREPARATION
(RE)LAPSE DETERMINATION
ACTION
PERMANENT
CHANGE? MAINTENANCE (Action > 6 months)
In a large studies in the United states involving 18,500 smokers that found 40% of
smokers are not Ready, 40% are Unsure, and 20% are in the Ready group (Velicer at al,
1995).
Not ready (Pre contemplation)
These tobacco users are not seriously considering quitting in the next 6 months. They
generally see the positive aspects of tobacco and do not like to acknowledge the
disadvantages or have been discouraged by failure in past quit attempts. Encourage
them to think about his/her tobacco use and invite them for any help. Offer them the
written information.
Unsure (Contemplation)
These tobacco user are seriously considering quitting in the next 6 months.. This group is
particularly amenable to brief motivational interviewing. Explore relevant health effect of
tobacco use and barrier to cessation. Find out other physical mental health issues of
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relevance and offer them help from your side. Provide them the written information and
tell them about support services.
Ready (Preparation)
These tobacco users are planning to quit in the next 30 days and have usually made a 24-
hour quit attempt in the past year. This group is motivated to quit soon and is the group
most likely to actually attempt to quit in the near future. This is a window of opportunity,
which may only open for a short time, and is the group most likely to ask for help with
quitting.
Action
These are former tobacco users who have quit in the last 6 months. This is when the risk
of relapse is highest with about 75% of relapse occurring in this stage, most within the first
week (National Health Committee, 1999). This is a period where support and strategies to
prevent relapse are especially important (see relapse prevention). If relapse does occur it
is important that this is not seen as a failure but a learning experience and a not
uncommon part of the quitting process.
Maintenance
These are tobacco users who quit over 6 months ago. The non-tobacco use behavior is
established and the threat of tobacco use gradually diminishes. The chances of relapse
diminish over time- only about 4% of those who quit for more than two years ever go back
to tobacco use.
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Cessation Plans or Strategies
Tapering (cutting) down (1 less cigarette today, 2 less tomorrow, etc.)
Cold turkey
Possibly a pharmacological method to assist with cessation
Although it has been used for verifying quitters (Smoking) of their habit. But in our
practice we have used as assessing tool / counseling tool for the client . This also helps
us to determine which method of treatment can be given to the subject (IJCD)
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Step 4: ASSIST — Aid the client to quit
WILLING TO QUIT
In tobacco users the motivational stage must be utilized properly. When they come for
help they must be assisted with care. The strategies to assist these clients is given in the
table - 1.
Table 1. Brief Strategies to Assist the Patient Wiling to Quit Tobacco Use
__________________________________________________________________________________
Action Strategies for implementation
Provide practical counselling Past quite experience-Identify what helped and what hurt in
(Problem solving/skills training) previous quit attempts.
Anticipate triggers or challenges in upcoming attempt – Discuss
challenges/triggers and how patient will successfully overcome
them.
Alcohol- Since alcohol can cause relapse, the patient should
consider limiting/abstaining from alcohol while quitting.
Other smokers in the household- Quitting is more difficult when
there is another smoker in the household.
Patients should encourage housemates to quit with them.
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Provide intratreatment social Provide a supportive clinical environment while encouraging the
support patient in his/her quit attempt. “My office staff and I are available
to assist you”.
_______________________________________________________________________________
Help patient obtain extratreatment Help patient develop social support for his/her quit attempt in
social support his/her environment outside of treatment.”Ask your spouse/partner,
friends, and coworkers to support you in your quite attempt.”
Recommend the use of approved Recommend the use of pharmacotherapies found to be effective.
Pharmacotherapy except in Explain how these medication is increase cessation
special circumstance success and reduce withdrawal symptoms. The firs-line
pharmacotherapy medications include; sustained-release
buy bupropion hydrochloride, nicotine gum, nicotine inhaler,
nicotine nasal spray, nicotine patch and vernicline
The first step to quitting is to decide to quit. Next make an appointment with your health care
provider, or contact TCC to discuss the options for treatment and to get a quit date
Quit date minus 5
- list all the reasons to quit
- Tell your family friends about your Plan
- Stop buying cartons of bidis/cigarette/smokeless tobacco
Quite date minus 4
- Pay attention to why and when to use tobacco
- Think new ways to relax
- Think new ways to hold something in mouth and in hand instead of tobacco
- Think of habits or routine you may want to change
- Make list of use when you quit.
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Quit day minus 3
- Make use of things you could do with extra money you save
- Think whom to reach when you need help
AFTER QUITTING
Congratulate yourself
Stay active
Drink lots of water
Do something that does not connect you with tobacco use
Take deep breath
Avoid high-risk situations where the urge to smoke is strong
Avoid coffee and alcohol
Avoid being around individuals who are smoking
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Table-2. Common Elements of Effective Counseling and Behavioral Therapies for
Smoking Cessation
Component Example
Practical Counseling (Problem Solving/Skills Training) Treatment
Identify events, internal states, or Negative affect
activities that increase the Being around other smokers
risk of smoking or relapse. Drinking alcohol
Experiencing urges
Being under time pressure
Identify and practice coping or Learning to anticipate and avoid temptation
problem-solving skills. Learning cognitive strategies that will reduce negative moods
Typically, these skills are Accomplishing lifestyle changes that reduce stress, improve
intended to cope with quality of life, or produce pleasure
dangerous situations. Learning cognitive and behavioral activities to cope with smoking
Urges (eg, distracting attention)
Provide basic information about The fact that any smoking (even a single puff) increase the
smoking and successful likelihood of full replapse
quitting. Withdrawal typically peaks within 1-3 weeks after quitting
Withdrawal symptoms include negative mood, urges to smoke,
and difficulty concentrating
The addictive nature of smoking
Intratreatment Supportive Interventions
Encourage the patient Note that effective tobacco dependence treatments are now
in the quite attempt available
Note that half of all people who have even smoked have now quit
Communicate belief in patient’s ability to quit
Communicate caring and Ask how patient feels about quitting
concern. Directly express concern and willingness to help
Be open to the patients expression of fears of quitting, difficulties
experienced, and ambivalent feelings
Encourage the patient to talk Ask about :
about the quitting process. Reasons the patient wants to quit
Concerns or worries about quitting
Success the patient has achieved
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Difficulties encountered while quitting.
Extratreatment Supportive Interventions
Train patient in support- Help videotapes that model support skills
solicitation skills. Practice requesting social support from family, friends, and
coworkers
Air patient in establishing a smoke-free home
Self Help:
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This therapy is validated and recommended for smoking cessation . Can be used
individually or with groups
Cognitive strategies
Cognitive or thinking strategies aim to use the power of logical thought to help overcome
the addiction to tobacco. Tobacco user can be encouraged to consider the benefits of
quitting and the consequences of starting to smoke again. The perceived benefits of
tobacco use can be challenged. Many users strongly believe they cannot cope with their
stress without tobacco but in fact when thy stop, they find thy can cope just as well, or
even better than when they were using tobacco.
Behavioral strategies
A number of behavioral strategies can be suggested to cope with the triggers and high-
risk situations. Ideally, the patient should suggest his/her own alternatives and substitute
activities. The 4Ds are an easy to remember mnemonic from Quit about behavioral coping
strategies:
Delay : Acting of the urge to smoke. After five minutes the urge to smoke weakens and
your resolve to quit will come back.
Deep breath : Take a ling slow breath in and slowly release it out again .repeat three
times.
Drink water : Slowly holding it in your mouth a little longer to savour the taste.
Do something else : To take your mind off smoking. Doing some exercise is a good
alternative.
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2. Remember The Three R's
Remind
Rehearse
Reward
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Withdrawal Symptoms
More than 80% of smokers will experience symptoms of nicotine withdrawal. Cravings for
tobacco and irritability are two of the most common symptoms. Withdrawal symptoms may
be lessened or prevented by using NRT or bupropion. If people are not using
pharmacotherapy then cognitive and behavioral strategies can be used to assist in the
early stage of the quit attempt. The worst of the physical symptoms are over within 2-3
days and most have passed after 10-14 days but can last up to 4 weeks.
The DSM-IV criteria for nicotine withdrawal are shown below
To meet the diagnostic criteria for nicotine withdrawal the following must also apply: the
symptoms cause clinically significant distress, are not due to a general medical condition
and are not accounted for by another medical disorder. Withdrawal symptoms of tobacco
products should be discussed with the client in advance so that he/she is able to prepare
for that. In addition, behavioral coping methods should be taught to the client. The
common withdrawal symptoms and coping strategies are described below
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Common symptoms and coping strategies are:
Craving for cigarette - Wait out urges, distract yourself, drink water, read, exercise
Withdrawal symptoms decrease as nicotine leaves the body and most symptoms are short
term
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NOT WILLING TO QUIT
For patients not ready to make a quit attempt, the healthcare provider should provide a
brief intervention designed to promote the motivation to quit and information about
harmful effect of tobacco. The client may have fears concerns about quitting, or may be
demoralized because of previous relapse. Such patients may respond to a motivational
intervention enter venture designed to educate, reassure and motivate. The components
of such motivational intervention build around the 5Rs: Relevance, risk, rewards,
roadblocks and repetition (described in detail in table below).
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Table : Enhanced motivation to quit in subjects not willing to quit this time7
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Step 4: ARRANGE
While dealing the follow up, the quitters has some common problems and a solution
should be given to them. The common problems and solutions are described in table
below
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Common Problems while quitting and solution
Problems Responses
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6. RELAPSE PREVENTION
Relapse prevention strategies aim to assist people to avoid or cope with high-risk smoking
situations. Such strategies also aim to prevents a lapse form occurring or if it occurs form
becoming a full relapse to smoking.
It is important to remember the reasons you want and need to stop tobacco. The first few
days to weeks after quitting will be the hardest. It is important to use self-discipline and
your most effective techniques to avoid giving in to the cravings. What some people find
helpful when urges come include:
Take a few deep breaths and let them out slowly.
Think about the most important reasons why you wanted to stop tobacco.
Don’t let negative thoughts dominate your thinking.
Use a coping strategy from your action plan.
Focus you attention away from the urge. Usually peak and subside within 5 to 10
minutes.
Go to a place where smoking is not permitted.
Seek support from a non-tobacco user friend.
Use a low-calorie substitute for oral stimulation.
Delay your use of tobacco for another hour
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Coping tips to stay a non-tobacco user for life
Once you quit tobacco, it’s time to focus your energy on avoiding the temptation to have
“just one cigarette/bidi”. To remain an ex- tobacco, you need to learn specific techniques
to help you cope with stress and situations that trigger your cravings for cigarettes.
Try any of these coping responses when faced with a relapse situation:
Remind yourself how hard it was to quit. Do you want to go through that again?
Have a nonalcoholic drink. Fruit juice, mineral water, and strongly flavored
decaffeinated tea are good choices.
Take to yourself. Say, “I can beat this,” “I can stay tobacco-free for one more
day,” or “I will not take tobacco”
Have a crunchy, low-fat snack, popcorn, or carrot sticks.
Take a short walk.
Excuse yourself and leave the room if someone lighting a cigarette triggers your
craving.
Run, do stretching exercises or walk the dog.
Brush your teeth.
Take several slow, deep breaths and think about how clear you lungs feel.
Do something with your hands-squeeze a rubber ball, play with a toothpick, coin,
or paper clip.
Remind yourself that smoking makes clothes, and hair smelly, dries skin, causes
premature wrinkles and turns teeth yellow.
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Type of Smoker/Reasons of Tobacco use and tips to help them
Reasons for Why smoking affects them Tips to help them quit
smoking
Smokes for Nicotine acts as a stimulant for some people Get enough sleep, Exercise regularly
energy take a brisk walk instead of smoking
Drink lots of water, Avoid getting bored
Likes to touch Oral fixation - nervous: needs to do Pick up a pen or pencil instead of a
and handle something with their hands cigarette and doodle
cigarettes Play with a coin, twist a ring, rub a
worry stone, carrot
Smokes when Nicotine acts as a depressant Use relaxation techniques when angry
tense or upset Many smokers have an underlying or upset
depression Avoid stressful situations
Take a hot bath, lie in outside and
relax, listen to soothing music
Addicted to Some people are genetically or socially Be aware of withdrawal symptoms and
nicotine predisposed to nicotine addiction. how to counteract them
Addiction can be physical or psychosocial. Need some form of NRT.
Those physically addicted will have the most quitting
challenge during withdrawal.
Smoking is habit Smoking has become a part of a routine such Change smoking routine
as talking on the phone, after dinner, etc. Keep cigarettes in a different place
Often lights up a cigarette but let it burn out in Don't do anything else while smoking
the ashtray. Limit smoking to a certain place
Be aware of cigarette smoked
Ask self if you really want this cigarette
Set a date to quit and stick to it
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7. SELF-HELP INTERVENTIONS FOR TOBACCO
CESSATION.
Many tobacco users give up on their own, but materials giving advice and information
may help them and increase the number who quit successfully.
Most commonly, self-help materials are printed leaflets or manuals, although use of
audiotapes and videotapes is also well established. The new generation of self-help
materials is computer-based on CDs or internet websites or linked to television programs.
Other forms of behavioural interventions that are predominantly self-help are client-
initiated telephone quit lines and Quit-and-Win competitions. Quit-line services provide a
contact point for provision of written self-help materials and may also employ counsellors
to assist and support people during cessation attempts. The quit-line number is promoted
extensively. The key elements for an effective quit-line are public access, quit tobacco
resources and information, counselling, training of counsellors and referral services .
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Minimal clinical intervention consists of brief cessation advice from health care providers
delivered opportunistically during routine consultations to tobacco users whether or not
they are seeking help with stopping tobacco. Brief opportunistic advice typically involves
asking patients about their current tobacco, advising them to stop, offering assistance
either by providing further advice, a referral to a specialist service, or recommendation of,
or a prescription for, pharmacotherapy, and arranging follow up where appropriate. This
approach has been described as the 5As interventions. The duration of each session of
minimal intervention is usually three to five minutes, and certainly less than ten minutes .
Barriers to the provision of tobacco cessation advice by all health professionals should be
identified and addressed. 'Lack of time' for example is often cited as a barrier to provision
of advice, yet the evidence confirms that clients can effectively be encouraged, advised
and supported to quit within as little as 3-5 minutes of a health professional's time. Lack of
perceived skills or training is another cited barrier, but existing evidence is mixed
regarding the added benefit of intensive cessation skills training. Lack of immediate
relevance is another barrier for health care providers who do not perceive a direct link
between tobacco use and the reason for presentation of their client/patient.
Brief advice from a heath care provider is recognized as an important motivator for a quit
attempt . However, the 5As approaches to minimal intervention stress the importance of
assisting clients to make a cessation attempt. This may include more intensive
behavioural therapy .A range of more intensive behavioural methods has been used in
clinical settings to support patient attempts at smoking cessation
These include:
a) Individual counselling
b) Supportive group sessions
c) Aversion therapy
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intervention becomes somewhat blurred when the clinician provides continuing support of
short duration per session.
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Attendance rates of smokers invited to participate in group cessation programs reviewed
by Stead and Lancaster (2000)(33) varied from 8 to 88 per cent. Group therapy can be an
effective cessation method that should be available for those who are willing to participate.
c) Aversion therapy
Adding an unpleasant (aversive) stimulus to an attractive behaviour reduces the
attractiveness and may extinguish the behaviour . Aversion therapy pairs the pleasurable
stimulus of smoking a cigarette with an unpleasant stimulus, with the aim of extinguishing
the urge to smoke.
The most frequently examined procedure has been rapid smoking. 'Rapid smoking'
usually consists of asking subjects to take a puff every six to 10 seconds for three
minutes, or until they consume three cigarettes or feel unable to continue. This is repeated
two or three times, and subjects are asked to concentrate on the unpleasant sensations it
causes. Explanation and supportive counseling is usually provided with application of the
rapid smoking technique. Other aversive techniques include rapid puffing (smoke not
inhaled), smoke holding, excessive smoking, paced smoking, self-paced smoking,
focused smoking, covert sensitization, symbolic aversion, electric shocks administered by
therapist or subject, and behavioural treatments with bitter pills.
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8. DEVELOPING A PLAN WITH YOUR CLIENT
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9. QUIT TOBACCO FOR BUSY PHYSICIANS
We know the physicians are very much busy and they do not get time to go in details
of tobacco cessation although they want to do so.
As physician you must advice--you’ve made the big decision to quit tobacco! You
have made the single best decision for your health. You can quit lots of different ways,
but the highest success rates for quitting include combining a tobacco cessation
class/counseling with medications. The important thing is to START.
Why Quit?
Why quit - - - you’ve done it for years, why stop now?
Very simply, you will greatly improve your health and improve your chances for a long life.
There are over 40 carcinogens (chemicals known to cause cancer) in cigarettes/beedis .
These greatly increase your odds of developing some type of cancer.
How to Quit
Why is it so hard to quit smoking? Nicotine is the answer. Nicotine stimulates the
“pleasure centers” of your brain and may make you feel relaxed, less tense, or happy, and
over the years you have learned to associate tobacco with a sense of well-being. You
know it’s unhealthy to keep using tobacco, so let’s learn how to quit one step at a time.
You will be most successful if you combine medications along with a behavioral
modification class or counseling.
Medication Options to Help You
Nicotine Replacement Therapy:
Bupropion
Verenicline
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Behavioral Options to Help You
Smoking Cessation Classes: Studies have shown that the best tobacco cessation
program includes individual or group counseling. When considering a program, ask
about the following:
1. Session length. It needs to be at least 20 –30 minutes long.
2. Number of sessions. Having at least 4-7 sessions is best.
3. Number of weeks. Attend for at least 4 weeks.
4. Make sure that your leader is certified to teach a smoking cessation
class/group.
Symptoms of Recovery
Take a positive approach and think of “withdrawal symptoms”, as your symptoms
of recovery! You body is healing and is recovering from an addiction. These
feelings or symptoms may not affect you at all or you may have only a few of them,
especially if you take medications.
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10. SMOKELESS TOBACCO AND HOW TO QUIT
Chewing tobacco comes in the form of long strands of loose leaves, plugs, or
twists of tobacco. Portions of this, commonly called "plugs," "wads," or "chew," are
chewed or placed between the cheek and gum or teeth. Nicotine is absorbed
through the mouth tissues. The user spits out the brown juice – saliva that soaked
through the tobacco.
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packaged in small pouches, but can also be used like loose moist snuff. The tobacco
related powers which are made are Pan Masala.
45
time. The good thing is, there are many sources of support out there – both formal and
informal.
Nicotine replacement therapy
Nicotine replacements (nicotine substitutes) give you nicotine without the other harmful
ingredients in tobacco. For cigarette smokers, nicotine replacement therapy (NRT) has
been proven to help reduce withdrawal symptoms. Together with counseling or other
support, it doubles the chances that a smoker will quit. Fewer studies have been done on
how much NRT helps smokeless tobacco users quit. Since both smokers and smokeless
users are addicted to nicotine, it makes sense to some smokeless tobacco users to try it.
These include:
nicotine gum
nicotine patch
nicotine lozenges
nicotine inhaler
nicotine nasal spray
Other medicines
Bupropion
Varenicline
46
11. TOBACCO CESSATION IN DENTAL CLINIC
Tobacco use is one of the leading preventable causes of illness and death. The most
powerful predictor of adult smoking is smoking during adolescence. While general and
pediatric dentists have a positive attitude regarding tobacco cessation counseling, the
same is not extrapolated into practice. Several barriers to counseling in the dental clinic
have been identified and research into some of these has been conducted. Evidence-
based cessation programs are still in the nascent stage, but this should not hinder dental
professionals from rendering these services to the child and adolescent populations. Brief
interventions, self-help materials, and nicotine replacement therapy for established
nicotine dependence form the mainstay of therapy.
Oral precancers
Tobacco use in any form has been shown to have a marked effect upon the soft tissues of
the oral cavity. Regular use of substances containing areca nut can cause oral
submucous fibrosis(OSF), a painful, debilitating condition in which the mouth tissues
gradually lose their elasticity and become tight. The diagnostic criterion is the presence of
palpable fibrous bands. In this condition, the ability to open the mouth decreases
gradually and can often reach an extend where only a straw can go inside the mouth.
This condition is becoming increasingly common, especially in individuals between 15 and
40 years of age, due to the increasing popularity of products containing areca nut and
tobacco. The use of these products (gutkha, mawa, paan masala) causes OSF in shorter
time than paan use.
47
Treat women of childbearing age and can inform them of the dangers of tobacco
use during pregnancy
Can spend more time with patients by physicians and other caregivers about the
dangers of tobacco use and the need to quit
Can reinforce messages given to patients by physicians and other caregivers
about the dangers of tobacco use and the need to quit
Can build their patients’ interest in discontinuing tobacco use by showing them the
actual effects in the mouth
Have a duty to promote oral health and healthy lifestyles among their patients.
Just 5 minutes of focused talk during the examination is enough to make the patient
aware and conscious of the harms of tobacco use. 5As are same as described earlier.
Mention your observations to the patient - this will help him or her face facts.
48
2. Advise patients
Brief Intervention: Available evidence suggests that behavioral interventions for tobacco
use conducted by oral health professionals incorporating an oral examination component
in the dental office and community setting may increase tobacco abstinence rates among
smokeless tobacco users. Dental treatment often necessitates frequent contact with
patients over an extended period of time, providing a mechanism for long-term contact
and reinforcement, coupled with visible changes in the oral cavity in response to
counseling.
It is important to note that studies report that adolescents consistently rank physical
attractiveness, dental concerns, and oral health as greatly important.?
Relating smoking to short-term adverse effects such as staining of teeth, bad breath, loss
of taste may be more relevant and meaningful to an adolescent smoker than relating
smoking to long-term health effects such as cardiovascular or lung diseases.
Peer influences play a critical role as do role models. Highlighting personalities abstaining
from smoking and making the dental clinic adopt a no tobacco policy can be used to guide
them away from tobacco use.
49
Eating healthy foods and exercising is a better way to lose weight than smoking.
The "5 A's" for brief intervention are used in cases where the persons wishes to quit and
include.
The 5 R's is recommended in the event that tobacco quitting is not being contemplated:
The self-help, non-interactive approach includes minimal interventions that do not require
responses from the adolescent and are delivered through written or audio-visual materials
or on a computer, while self-help, computer interactive support approach uses computer
technology to assess a person's tobacco use and motivation to quit.
50
12. TOBACCO CESSATION AT SPECIAL
SITUATIONS
Cardiovascular disease
In stable cardiovascular disease NRT is safe, although caution should be maintained
while considering NRT in the patients of unstable angina, myocardial infarction, or stroke
as nicotine is vasoconstrictor. However medicinal nicotine is unlikely to be more harmful
compared to continued intake of nicotine through tobacco smoke. In these cases rapidly
reversible NRT like nicotine gum or nasal spray should be preferable to nicotine patch as
with nicotine patch absorption of nicotine may continue through skin even after removal of
patch.
51
People with mental illness
People with mental health problems have high rates of smoking (estimated form
50-80%). Mental illness is not a contraindication to stopping smoking but the
illness and its treatment need to be monitored carefully during smoking cessation.
52
Brief Smoking Cessation Counseling for Pregnant Patients
ASK – 1 minute
Ask patient about smoking status.
A. I have NEVER smoked, or have smoked LESS THAN 100 cigarettes in my lifetime.
B. I stopped smoking BEFORE I found out I was pregnant, and I am not smoking now.
C. I stopped smoking AFTER I found out I was pregnant, and I am not smoking now.
D. I smoke some now, but I cut down on the number of cigarettes I smoke SINCE I
found out I was pregnant.
E. I smoke regularly now, about the same as BEFORE I found out I was pregnant.
If patient responds D or E, document smoking status on her clinic chart, and proceed to
ADVISE, ASSESS, ASSIST and ARRANGE.
ADVISE – 1 minute
Provide clear, strong advice to quit with personalized messages about the impact of smoking
on mother and fetus.
ASSESS – 1 minute
Assess the willingness of the patient to make a quit attempt within the next 30 days.
ASSIST – 3 minutes +
Suggest and encourage the use of problem-solving methods and skills for cessation.
Provide social support as part of the treatment.
Arrange social support in the smoker’s environment.
Provide pregnancy-specific, self-help smoking cessation materials.
ARRANGE – 1 minute +
53
13. HOW TO START TOBACCO CESSATION SERVICES
There will be some mandatory and some optional logistics which are needed for
the same. In 2002 Govt. of India with the help of WHO started the 13th Tobacco
Cessation Clinic. These clinics later on ended to 19 now and with the expances
they were called as Tobacco Cessation Centres. The services provided by
Tobacco Cessation Centres are in the OPD, Community and related to research
activities. It is very important to know how to start the Tobacco Cessation Centres
by any one with the help of Govt. of India their own. This Chapter will discuss the
logistics of studying the TCC.
Targets
i) Specific targets
Current smokers
Current SLT users
Families of these people
Aim is to make current users quit and to keep others from getting into the vicious cycle of
tobacco
Plan
Infrastructure
Location
54
Staff recruitment
Pre-launch publicity
Launch
Post-launch publicity (on continuous basis)
Infrastructure
One room for OPD services equipped with all necessary furniture and equipments
including computer
Staff recruitment
Doctor
Counselor
Social worker
Computer operator
Attendant
Location
TCC Services should be located in a place which is well connected with roads and
public transport
It can be open as a part of an existing government hospital – as that way it is easier
for people to approach the Centre.
55
Publicity should be done in all major newspapers and FM radio channels (as FM
channels attract large number of audience) and if economically viable then publicity
through the medium of TV can be considered
Launch should be preceded by adequate training of the staff recruited for the
purpose by the centres who are already providing such services
Publicity of the clinic should be done on a continuous basis so that it continues to
attract people
Equipments/Hand outs
Besides follow up is significantly better in persons getting medicines from our centre
Quit rate is also better in people getting medicines from the centre itself
56
Contact with Alcohol de-addiction centers List and complete addresses of all major
alcohol de-addiction centers should be available at the clinic so that the people who need
these services are referred to the appropriate centers
(this is based on our observation at our tobacco cessation clinic where many smokers are
heavy drinkers and they also want to get rid of alcohol)
IMPORTANT
Tobacco Cessation Services be part of other services of Hospital
hence there is no need of any extra logistics. Only there is a
need of preparing the staff and commencement of Services.
57
14. PHARMACOTHERAPY
Nicotine patch: Nicotine patch is available in doses of 7mg, 14mg, and 21mg.
Recommended prescription dosage schedule7 is 21mg/24hours for four weeks followed
by 14mg/24hours for 2 weeks and 7mg/24hours for another 2 weeks. Other dosage
schedule recommendation28 is to give 21mg/24hours followed by 14mg/24hours and
58
7mg/24hours for 2 weeks each. In subjects complaining of insomnia patch should be used
for 16 hours instead of 24 hours28.
Nicotine gum: Nicotine gum is available in the doses of 2mg and 4mg. Recommended
dosage7 is 2mg gum (upto 24 pieces per day) for smokers who smoke 1 to 24 cigarettes
per day, and for those who smoke≥25 cigarettes per day 4 mg gum (upto 24 pieces per
day) is recommended. Treatment is continued for 12 weeks. Subjects are advised to chew
the gum till the peppery taste emerges and then to keep it between the cheeks and gum,
to be re-chewed when the taste fades. Nicotine gum is associated with mouth soreness
and dyspepsia.
Nicotine inhaler: Even though it is called inhaler but the device does not deliver the
significant amount of nicotine into the lung, rather it delivers nicotine buccally30
irrespective of whether the breath is shallow or deep. For the same reason its
pharmacokinetics is similar to nicotine gum. Advantage of nicotine is its external
resemblance to cigarette31 because of which it provides psychological fulfillment of
cigarette smoking. Nicotine inhaler is shown to double the cessation rates compared to
control (placebo)31.
Nicotine nasal spray: delivery of nicotine through nasal spray is more rapid compared to
other NRTs, however it still does not match the swiftness with which the tobacco smoke
inhalation delivers the nicotine32 . Peak levels, which are two-third of what is achieved by
cigarette, are reached in 10 minutes. Nicotine nasal spray is shown to be especially
helpful in highly dependent smokers33 in earlier studies but later studies does not show
such advantage. In the early phase of treatment nasal spray is associated with nasal and
throat irritation, rhinitis, sneezing, coughing and watering of eyes but tolerance to these
develop in one week31
.Combination of bupropion and nicotine patch: bupropion can be used in combination
with nicotine patch especially in heavy smokers. Studies have shown combination of
bupropion and nicotine patch is associated with higher quit rates compared to when
bipropion and nicotine patch are used alone31.
Verenicline:
is a newer prescription medicine taken as a pill twice a day. It works by interfering with
nicotine receptors in the brain. It lessens the physical pleasure from taking in nicotine and
59
helps lessen the symptoms of nicotine withdrawal. Studies have shown it to work as least
as well as bupropion (if not more so) in helping people quit smoking, at least in the short
term. Its effects against smokeless tobacco have not been studied.
Second line pharmacotherapies
Special cases
60
Clonidine 0.15mg to 0.75mg/day for 3 Dry mouth, Rebound
to 10 weeks dizziness hypertension
drowsiness,
sedation
Nortryptyline 75 to 100mg/day for 12 Sedation, dry Risk of arrhythmias
weeks mouth
Prevent Relapse
Most relapses within 3 first months
Desire to quit smoking
Reinforce decision to quit
Follow up The 5 A’s Yes
Assist resolving residual problem No
No The 5 R’s
No severe Severe
co-morbidities co-morbidities
61
14. OTHER FORMS OF THERAPY
Acupuncture
Acupuncture as an aid to smoking cessation has been the subject of a number of
controlled studies. Two meta-analyses have reviewed the results of controlled
studies (While et al, 1990, Flore et al, 2000). There was no significant difference
between ‘active’ acupuncture of ‘inactive’ or sham acupuncture procedures.
Hypnotherapy
Hypnoherapy as an aid to smoking cessation has been the subject of a number of studies,
including some controlled trials but the Cochrane systematic review (Abbott et al, 2002)
concluded that there was such heterogeneity between methods and results that a meta-
analysis of the literature was not possible at that time. The review concluded that
hypnotherapy does not show a greater effect on six month quit rates than other
interventions or no treatment.
Yoga therapy
62
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6. Department of Health and Human Services (DHHS). Special Populations. Treating
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10. National Cancer Institute (NCI). Why Do You Smoke? National Institutes of Health
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11. First Time Quitter Handout
12. Tobacco Use Log Handout
13. Helping Patients Overcome Trigger Situations Handout
14. Indiana State Department of Health (ISDH) and MCH. Quit Attempts: Why People
Who Stop For Good May Quit More Than Once. AHCPR.
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15. One Day at a Time Handout
16. Fronske Health Center. Preparing to Quit Smoking, Northern University University,
1999.
17. North Carolina Project Assist. Guide for Counseling Women Who Smoke, 1995.
18. You Really Are OK Handout
19. How Much Smoking Costs You Handout
20. Reward Yourself for Short and Long-Term Goals Handout
21. Centers for Disease Control and Prevention. Tobacco Use Among Adults—United
States, 2005. Morbidity and Mortality Weekly Report [serial online].
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http://www.in.gov/isdh/dataandstats/mch/IN_Infant_Mortality_Rpt2002.pdf
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http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2001/sgr_women_chapters.ht
m
24. Peto R, Lopez AD, Boreham J, Thun M, Heath C Jr. Mortality from tobacco in
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25. Peto R, Lopez AD, Boreham J, Thun M, Heath C Jr. Mortality form smoking in
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26. Peto R. Smoking and death: the past 40 years and the next 40. Br Med J, 1994,
309: 937-39.
27. Robert West. ABC of smoking cessation: Assessment of dependence and
motivation to stop smoking. BMJ 2004; 328:338-9.
28. Fagerstrom KO, Heatherton TF, Kozlowski LT. Nicotine Addiction and its
Assessment. Ear Nose Throat J. 1990; 69(11): 763-5.
29. West R, McNeil A, Rao M. Smoking cessation guidelines for health professionals:
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30. A clinical practice guideline for treating tobacco use and dependence – A US
public health service report. JAMA. 2000; 283:3244-3254.
31. Tim Coleman. ABC of smoking cessation: Use of simple advice and behavioural
support. BMJ 2004; 328:397-9.
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32. Fagerström K. ed. Smoking cessation treatment with sustained release Bupropion:
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33. Prochazka AV. New Developments in Smoking Cessation. Chest 2000; 117(4):
169S-75S.
34. Coleman T. Smoking Cessation: Integrating recent advances into Clinical
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35. Rundmo T, Smedslund G, Gotestam KG. Motivation for smoking cessation among
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antidepressant activity. J Clin Psychiatr. 1995; 56:395-401.
38. Ferry LH, Burchette RJ. Efficasy of bupropion for smoking cessation in non-
depressed smokers. J Addict Dis. 1994; 13:249.
39. Hurt RD, Sachs DPL, Glover ED, et al. A comparison of sustained-release
bupropion and placebo for smoking cessation. N Engl J Med. 1997; 337: 1195-
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40. Hayford KE, Patten CA, Rummans TA, et al. Effectiveness of bupropion for
smoking cessation in smokers with a former history of major depression or
alcoholism. Br J Psychiatry. In press
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Cessation in Patients with Chronic Obstructive Pulmonary disease: a double blind
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trial of sustained release Buproprion, a nicotine patch or both for Smoking
Cessation. N Eng J Med 1999; 340: 685-91.
43. Hurt RD, David PL, Glover ED, Offord KP, Johnston JA et al. A comparison of
sustained release Bupropion and Placebo for smoking cessation. N Eng J Med
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44. Hayes JT, Hurt RD, Rigotti, NA, Niaura R, Gonzales D. Sustained – Release
Bupropion for pharmacologic Relapse Prevention after smoking cessation. Ann
Inter Med.2001; 135: 423-33.
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45. Holm KJ, Spencer CM. Bupropion. A review of its use in the management of
smoking cessation. Drugs 2000; 59(4):1007-24.
46. Andrew Molyneux. ABC of smoking cessation-Nicotine replacement therapy. BMJ.
2004; 328:454-6.
47. Pontieri FE, Tanda G, Orzi F, Chiara GD. Effects Nicotine on Nucleus accumbens
and similarity to those of addictive drugs, Nature 1996; 382:285-7.
48. Dani JA, Biasi MD. Cellular Mechanisms of Nicotine Addiction. Pharmacol
Biochem Behav 2001; 70 (439-446).
49. Silagy C, Mant D, Fowler G, Lancaster T. Nicotine replacement therapy for
smoking cessation. Database of abstracts of reviews of effectiveness. In: The
Cochrane Library, Issue 2. Oxford: Update Software, 1998.
50. Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Goldstein MG, Gritz ER, et al.
Smoking cessation. Rockwille, MD: Agency for Health Care Policy and Research,
US Department of Health an Human Services, 1996. (Clinical practice guideline
No 18. Publication No 96-0692.)
51. Raw M, Mcneill A, West R. Smoking cessation: evidence based recommendations
for the healthcare system. BMJ. 1999; 318:182-5.
52. Benowitz NL, ed. Nicotine safety and toxicity. New York: Oxford University Press,
1998.
53. Bergstrom M, Nordberg A, Lunell E, Antoni G, Langstrom B. Regional deposition
of inhaled 11C-nicotine vapour in the human airway as visualized by positron
emission tomography. Clin Pharmacol Ther. 1995; 57:309-17.
54. Hughes JR, Goldstein MG, Hurt RD, Shiffman S. Recent advances in the
pharmacotherapy of smoking. JAMA. 1999; 281:72-76.
55. Schneider NG, Lunell E, Olmstead RE, Fagerstrom K-O. Clinical pharmacokinetics
of nasal nicotine delivery: a review and comparison to other nicotine systems. Clin
Pharmacokinet. 1996; 31:65-80.
56. Sutherland G Stapleton JA, Russell MAH, et al. Randomized controlled trial of
nasal nicotine spray in smoking cessation. Lancet. 1992; 340:324-29.
57. Clinical Practice Guideline. Treating Tobacco use and Dependence. US
Department of Health & Human Services. Public Health Service. June 2000.
58. Burton SL, Kemper KE, Baxter TA, Shiffman S, Gitchell J, Currence C. Impact of
promotion of the great American smoke out and availability of over-the-counter
nicotine medications, 1996.
66
(Appendix – I)
Tobacco Cessation Data Collection Form (for understanding)
Ask
Current tobacco user? If no, recent quitter? Number of tobacco in household Tobacco last ?
Yes No Yes No Yes No
Amount tobacco per day Age began tobacco Number of years tobacco used Number previous quit attempts
Assess
1. ASSESS readiness to Quit 2. ASSESS Level of Addiction
P (Precontemplation) Not interested in quitting/not ready Fagerstrom Questionnaire
yet 3. ASSESS Level of Knowledge
C (Contemplation) Willing to learn more about quitting 4. ASSESS Barriers
R (Preparation) Ready to Quit Stress, weight gain, withdrawal,
Q (Action/maintenance) Recent Quitter family smokers
Assist
Assist With Education/Quitting Plan
Health Messages: C (effects on child), M (effects on mother), B (benefits of quitting,),
N (nicotine addiction)
Education Program materials
C M B N
Quit date Written plan Quit contract signed No tobacco support
Yes No Yes No
Arrange/Follow-up
Referred to cessation Type of intervention Nicotine Replacement Other
program One-to-one Group Patch Gum Inhaler Bupropion
In-house Outside Spray Verniciline
Set follow-up date Type of follow-up Reduced Tobacco use Stopped tobacco use
Phone Letter Yes No Yes No
Visit
67
(Appendix – II)
Nicotine addiction questionnaire
Are you addicted to nicotine? Take the test below and see what you rank. After you
score is totaled, you will be given tailored advice on what methods or treatments are
available to help make your decision to a tobacco free life easier.
1. How soon after you wake up do you smoke your first cigarette?
0-5 min 6-30 min 31-60 min After 60 min
2. Do you find it difficult to refrain from smoking in places where it is forbidden (e.g.,
church library, cinema)?
Yes No
5. Do you smoke more frequently during the first hours after waking than during the rest
of the day?
Yes No
6. Do you smoke if you are so ill that you are in bed most of the day?
Yes No
1. How soon after you wake up do you smoke your first cigarette?
0-5 min 6-30 min 31-60 min After 60 min
(3 points) (2 points) (1 point) (0 points)
68
2. Do you find it difficult to refrain from smoking in places where
it is forbidden (e.g., church library, cinema)?
Yes No
(1 point) (0 points)
5. Do you smoke more frequently during the first hours after waking than during the rest
of the day?
Yes No
(1 point) (0 points)
6. Do you smoke if you are so ill that you are in bed most of the day?
Yes No
(1 point) (0 points)
69
(APPENDIX – III)
HAND OUTS
70
(Appendix – IV)
71
Dr U. R. Parija
Head of Department of Neck Oncology
Acharya Harihar Regional Cancer Centre
5. Medical Road, Manglabad, Cuttack –753007
# 0671-2614264 (O) # 0-9437023451 (M)
E-mail: usaranjan@sify.com
72
Dr. Pratima Murthy
Principal Investigator (Tobacco Cessation Clinic)
National Institute of Mental Health and Neuro Sciences (NIMHANS),
Deemed University, Bangalore, Karnataka
# 0-98440-94482
E-mail: tccbangalore@rediffmail.com
9. E-mail: pratimamurthy@gmail.com
E-mail: pratimamurthy_2000@yahoo.com
Dr. E. Vidhubala
Principal Investigator (Tobacco Cessation Clinic)
V-I-Block, Room No 19, Cancer Institute (WIA)
Number-38,Sardar Patel Road,Chennai-600036, Tamil Nadu
11. # 0-94442-74700 (M)
E-mail: chennaitcc@yahoo.co.in
Concerned TCC Staff
Ms. V. Preethi -09940382971
Dr. R Jayakrishnan
Co-Investigator (Tobacco Cessation Clinic)
Regional Cancer Centre (RCC)
Post Box 2417,Medical College Campus
14 Thiruvananthapuram-695011, Kerala
Tel: 0471-2443128 (O) # 09961241372 (M)
E-mail: jayrish71@yahoo.com
E-mail: tcc@rcctvm.org
73
Dr. T. Mandapal
Director & Principal Investigator (Tobacco Cessation Clinic)
MNJ Institute of Oncology & Regional Cancer Centre
Red Hills,Hyderabad – 500004, Andhra Pradesh
# 040-23318414/22/24 (0)
15 E-mail: tcchyderabad@yahoo.co.in
74
(Appendix –V)
TOBACCO CESSATION CLINIC- INTAKE AND FOLLOW-UP FORM
Note: This is the minimum required information for the database. Each center is
encouraged to maintain a detailed clinical record for each client.
Centre Centre code Client No.
Date
1. Name : __________________________________________________________
2. Age : __________________________
3. Gender : Male Female
4. Address : ___________________________________________________________
___________________________________________ Ph. No. _________________
5. Education (Numbers of years of formal education) _____________________________
6. Marital Status: Unmarried Married Widowed
75
Smokeless
1.
2.
3.
Smoking
1.
2.
3.
11. Expense per month on tobacco (Average month last year) Rs. __________________
12. Alcohol use in the last 1 year: Daily Drinking Regular Drinking (3 or more times a week)
15. Number of previous attempts at quitting which lasted for at lasted one month ___________.
16. Severity of Tobacco use (applicable for the last one Month):
1. How soon after you wake up, do you smoke your first cigarette/ bidi/your first packet?
3- Within 5 min. 2- 6 to 30 min. 1-31 to 60 min 0- more than 60 min
2. Do you find it difficult to refrain from smoking/chewing in place where it is forbidden?
(Such as religious places/ classroom/ hospital etc.) 1- Yes 0-No
7. How long do you keep the betel quid / khaini / ghutkha etc in your mouth in a day? (In hours)
17. Tobacco use in first \-degree relatives: Smoking Smokeless Both None
18. History & Symptoms suggestive of: HTN (yes, No) Diabetes (Yes, No)
76
25. Intervention: Behavioural Counselling Behavioural Counselling+ Medication
26. Fellow up
Date No Change Reduced use Stopped Lost to Continine test
(or<50% (50% or greater Use fellow up (+ve or_ve) or not
reduction reduction from done
from baseline*) baseline*)
2 weeks
4 weeks
6 weeks
3 months
6 months
77