tobacco cessation

1. TOBACCO CESSATION
Presented by:
M.Jyothi,
PG III yr
Guided by:
Dr. Yadav sir.

2. CONTENTS
• INTRODUCTION
• WHAT IS TOBACCO ?
• HISTORY OF TOBACCO
• TYPES OF TOBACCO USE
• TOBACCO BURDEN
▫ GLOBAL
▫ INDIAN
• HARMFULL EFFECTS OF TOBACCO USE
▫ SMOKE FORM
▫ SMOKELESS FORM
▫ PASSIVE SMOKE(SECOND HAND SMOKE)
▫ THIRD HAND SMOKE
▫ TOBACCO AND PREGNANCY

3. • PREVENTION AND CONTROL OF TOBACCO USE
• TOBACCO DEPENDENCE
• BEHAVIOURAL INTERVENTIONS
• STRATEGIES FOR TOBACCO CESSATION - THE 5 “A”S AND
5 “R”S
• STEP 1: ASK
• STEP 2: ADVISE
▫ BENEFITS OF QUITTING
• STEP 3: ASSESS
▫ ASSESSING A TOBACCO USER’S READINESS TO CHANGE THE
BEHAVIOUR.THE STAGES OF READINESS TO CHANGE MODEL
▫ ASSESSMENT OF NICOTINE DEPENDENCE— IF THE TOBACCO
USER IS IN THE READY STAGE

4. • STEP 4 – ASSIST
• PHARMACOTHERAPY
• NON PHARMACOLOGICAL CESSATION STRATEGIES
• WITHDRAWAL SYMPTOMS
• FOR TOBACCO USERS WHO ARE NOT READY TO MAKE A
QUIT ATTEMPT
▫ THE 5 “R”S APPROACH
• STEP 5: ARRANGE
• SELF HELP IN INTERVENTION FOR TOBACCO CONTROL
• SMOKELESS TOBACCO HOW TO QUIT??
• TOBACCO CESSATION IN DENTAL CLINIC
• TOBACCO CESSATION IN SPECIAL SITUATIONS
• GLOBAL TOBACCO CONTROL
• TOBACCO CONTROL IN INDIA
• CONCLUSION
• REFERENCES

5. INTRODUCTION
• Tobacco is the major cause of preventable mortality and morbidity
all over the world
• The World Health Organization (WHO) estimates that annually
nearly 5 million people are killed by tobacco-related illnesses.
• If current trends continue, it is projected that by 2030, tobacco will
be responsible for more than 8 million deaths each year
• Tobacco use is a global epidemic that kills 5.4 million people
annually, tragically, more than 80% of those deaths occurs in the
developing countries.

6. • In India, trends in consumption of tobacco, incidences of tobacco
related cancers and other illnesses
• Tobacco-related mortality in India is among the highest in the
world, with about 700,000 annual deaths attributable to smoking in
the last decade (Gajalakshmi et al., 2003), expected to increase to
1million in the current decade.

7. • About half of teenagers who use tobacco will eventually be killed
by it.
• Annual oral cancer incidence in the Indian subcontinent has been
estimated to be as high as 10 per 100,000 among males (Moore SR
et al, 2000) and oral cancer rates are steadily increasing among
young tobacco users.
1.40%
13%
1990 2020
Deaths in India due to tobacco
deaths

8. • Passive smoking causes health problems for children and other
family members.
• The burden will not just be in terms of death and illness but also
reduced productivity and increasing health-care costs.
• However, all is not lost. If effective tobacco control measures, along
with treatment, are made available, and the adult tobacco
consumption halves, millions of deaths can be prevented.

9. Tobacco and its history:
• It is thought to be derived from the Arabic word tabaq,
meaning ‘euphoria producing herb’.
• Cultivation of the tobacco plant probably dates back 8000 years by
American Indians through the southern and northern American
continent.
• It belongs to family Solanaceae, night shade family

10. • Native Americans began using tobacco for medicinal and
ceremonial purposes before 1 BC.
• The documentation of the practice of inhaling the smoke of dried
tobacco plants is available from the Mayan culture as early as the
sixth century.
• Christopher Columbus in 1492 first observed these tobacco
leaves.
• In 1493, Ramon Pane, who accompanied Columbus first person to
introduced tobacco seeds into Europe.

11. • Through Columbus crew journey of tobacco went to Spain and
introduced its cultivation in Spain.
• Jean Nicot was instrumental in introducing tobacco into Europe.
• He cured migraine pain using powdered tobacco.
• The tobacco plant thus got its generic name, Nicotiana after Jean
Nicot.
• Though the tobacco plant came to Europe through Spain, smoking
as a habit became popular in the continent from England.

12. • Portuguese traders introduced tobacco in India during 1600.
Tobacco became a valuable commodity in barter trade and its use
spread rapidly.
• Gradually tobacco got assimilated into the cultural and social
practices due to presumed medicinal and actually addictive
properties attributed to it.

13. Medicinal attributes of tobacco:
• In the sixteenth century a leading physician of Seville, Nicolas
Monardes, reported the medicinal properties of tobacco, identifying
25 ailments that tobacco could ‘cure ’—ranging from toothache to
cancer.
• According to the European humoral system of medicine all diseases
were believed to be caused due to imbalances, e.g. excess heat and
excess moisture.

14. • Tobacco was believed to have the power to expel excess moisture
from the body.
• The Chinese Yang–Yin (hot–-cold) medical system also classified
tobacco to be having similar medicinal properties and effects on
body.
• Our Indian ayurvedic system even followed hot & cold system but
never recommended medicinal use of tobacco.

15. • A description of the tobacco plant, its ‘medicinal’values and adverse
effects is found in Yogaratnakara
• It is said to facilitate smooth intestinal functioning and motion,
prevent toothache by killing germs, cure itching on the skin, control
wind in the body.
• Adverse effects of tobacco use are also indicated in this work such
as ‘giddiness, weakening in eyesight, and making semen less virile’.

16. TYPES OF TOBACCO USE
Smoked forms of tobacco use:
• Bidis, Cigarettes, Chuttas, Dhumti, Chillum, Hookah.
Smokeless forms of tobacco use:
• Paan with tobacco, preparations, Gutkha, Mawa, Khaini, Mishri
etc

18. BURDEN
Global
• 1/3rd of world population-Smoker
▫ Males: > 1 billion
▫ Females: > 250 million
• Industrialized Countries
▫ % of Male smokers: 50%
▫ % of Female smokers 22%
• Developing countries
▫ Males 31%
▫ Females 8%

19. • 6 million die each year
• >80% deaths occurring in developing countries
• Ten million deaths annually expected by 2020 - means one death
after every three seconds.
• In 2013 study showed that the majority of young children in low-
and middle-income countries could correctly identify cigarette
brand logos, and nearly a third of children in India reported that
they wanted to smoke when they grow up.

20. INDIA
• There are almost 275 million tobacco users in India(2009-2010).
• Among adults (age 15+), over one-third (35%) of the population use
tobacco products, with 48% of males and 20% of females using
some form of tobacco.
• Among youth (age 13-15), 4% smoke cigarettes (boys 5%; girls
2%).
• Almost 12% of youth use other types of tobacco products (boys
14%; girls 8.5%).
• Bidis are the most popular tobacco product used. Bidis comprise
48% of the tobacco market, chewing tobacco 38% and cigarettes
14%.

21. HARMFULL EFFECTS OF TOBACCO USE
1) Smoke form
2) Smokeless form
3) Passive smoke(second hand smoke)
4) Third hand smoke

22. SMOKE FORM
The major health effects of cigarette smoke include:
• Cancer;
• Noncancerous lung diseases;
• Atherosclerotic diseases of the heart and
blood vessels;
• Toxicity to the human reproductive system.

23. Important constituents and effects:
• Nicotine: Powerful addictive drug. Causes increase in heart rate and
blood pressure. Has adverse effects on cardiovascular health.
• Carbon monoxide: Acts as an added stress factor to precipitate
cardiovascular disease. It combines with haemoglobin to form
carboxyhaemoglobin, which reduces the oxygen carrying capacity
of the blood.
• Hydrogen cyanide: Respiratory irritants that paralyses ciliary
movement.

24. • Acrolein: Respiratory irritants that paralyses ciliary movement.
• Phenol: Respiratory irritant and tumor-producing chemical.
• Polyaromatic hydrocarbons (PAHs), particularly benzopyrenes:
Potent lung carcinogen.
• Tobacco–specific Nitrosamines (TSNAs): Carcinogen.(NNN)

25. • Nickel, Arsenic, lead, cadmium, chromium etc
• Tar, polonium 210, vinyl chloride, benzene etc
• Nitric oxide, ammonia, hydrogen cyanide etc

26. SMOKELESS FORM
• The major health consequences associated with smokeless tobacco
use include.
• Cancers of several sites (e.g. the upper respiratory and digestive
tracts)
• Poor reproductive outcomes.
• Blood pressure and cardiac disease.
• In addition, use of areca nut, often chewed with tobacco, can
predispose to diabetes mellitus and aggravate asthma.

27. Adverse effects on pregnancy:
• Threefold increase in stillbirths and a 100–400 g decrease in birth
weight, in off springs of women who chewed tobacco during
pregnancy.
Asthma:
• Asthma patients who chew betel quid with or without tobacco may
find their condition aggravated by the arecoline from areca nut,
which induces the contraction of bronchiolar smooth muscle.

28. Second-hand and Third-hand smoke:
• Secondhand smoke is the smoke that comes from the burning end of
a cigarette, cigar or pipe. It is also the smoke that smokers breathe
out (exhale).
• Third-hand smoke is the invisible tobacco “dust” (or chemical) that
settles in the environment and stays there even after a cigarette has
been put out.

29. • The smoke from the burning end of a cigarette has more toxins than
the smoke inhaled by the smoker.
• Affect young infants and children adversely.
• Presents health hazards comparable to smoking.
• Also contains toxins and carcinogens, and breathing it in for as little
as 20 or 30 minutes can cause harm.
• Health risks include cancer (including cancer of the nasal sinuses),
cardiovascular diseases and lung disease(Asthma)

30. • More susceptible to both upper and lower respiratory tract infections
and have reduced lung function.
• Middle ear infections are also more likely in children living in
smoking households.
• chronic cough, wheezing, eye and nose irritation, and irritability are
the other problems.

33. TOBACCO AND PREGNANCY
Smoking form of tobacco use
The effects include higher risk of
• Abortion or Miscarriage
• Ectopic pregnancy
• Stillbirths
• Intrauterine growth retardation
• Prematurity
• Low birth weight.
• Birth defects such as cleft palate and digital anomalies.
• There is a greater risk of sudden infant death syndrome (SIDS),
particularly in children born to mothers who actively smoke during
pregnancy.

34. • Reduced lung function in infants, and may lead to increase in the
number of respiratory tract infections during infancy.
• Impaired lung function during childhood and adulthood.
• Smokeless tobacco use during pregnancy has also been shown to
have a range of adverse reproductive outcomes, including
1) increased rates of stillbirths
2) prematurity and
3) lower birth weight.

36. PREVENTION AND CONTROL OF TOBACCO USE
• Tobacco use is a leading cause of preventable deaths all over the
world.
• Tobacco is also one of the major causes of deaths and diseases in
India, accounting for almost a million deaths every year.
• Global Adult Tobacco Survey (GATS) India (2010) data revealed
that more than one out of three adults in India (35%) used tobacco
in some form or the other.
• Among them, 21 % of adults used only smokeless tobacco, 9% only
smoked and 5 % smoked as well as used smokeless tobacco.
• Indian males 48 % females 20 %.

37. • As per the Global Health Professions Student Survey (GHPSS),
India, 2009
• 6.5% third year dental students smoked cigarettes and 8.6% used
other tobacco products.
• Among medical students, 13.4% third year medical students smoked
cigarettes and 11.6% used other tobacco products.
• Global Youth Tobacco Survey(GYTS) India, 2009 revealed that
14.6% of 13-15 years school going children in India used tobacco
products out of which 4.4% smoked cigarettes and 12.5% used other
forms of tobacco.

38. TOBACCO DEPENDENCE
• Tobacco dependence is defined as, “Cluster of behavioral, cognitive
and physiological phenomena that develop after repeated tobacco
use and that typically include a strong desire to use tobacco,
difficulties in controlling its use, persistence in tobacco use despite
harmful consequences, a higher priority given to tobacco use than
other activities and obligations, increased tolerance and sometimes a
physical withdrawal state”.

39. • Both smoked and smokeless forms of tobacco contain nicotine, a
highly addictive chemical, making it difficult for habituated tobacco
users to quit.
• Nicotine is readily absorbed from the respiratory tract, buccal
mucosa and skin.
• Inhaled nicotine takes about 10-19 seconds to reach the brain and its
stimulation releases chemicals which ensure feeling of goodness,
alertness and energy.

40. • As the person stops tobacco use, these chemicals decrease in the
body and withdrawal symptoms start.
• These can be very distressing for the unprepared tobacco user.
• Thus, the tobacco user is compelled to continue using tobacco,
hence trapped in the vicious cycle.

42. s

43. TOBACCO DEPENDENCE TREATMENT
• Tobacco smoking is a learned behaviour that results in a physical
addiction to nicotine for the majority of smokers.
• Tobacco dependence is a chronic condition that often requires
repeated interventions.
• Because effective tobacco dependence treatments are available,
every patient who uses tobacco should be offered at least one of
these treatments.

44. • Accordingly, stopping smoking can be difficult for many
individuals, and it is recommended that interventions include
behavioural and pharmacological support.
• when seeking to quit abruptly, a combination of behavioural
support and pharmacotherapy is recommended.
• Tobacco dependence treatments are both clinically effective and
cost effective in relation to other medical and disease prevention
interventions.
• Costs per quality adjusted life year (QALY) for all smoking
cessation interventions (brief and more intensive and those
including pharmacotherapy) are low.

45. • BEHAVIOUR INTERVENTIONS:
• Smoking cessation interventions are commonly influenced by
theories of behaviour change, including the Transtheoretical model,
the Health Belief Model and/or Social Cognitive/Learning theory.
• Health belief model(Becker): This model proposes that when an
individual considers changing behaviour they engage in cost/benefit
analysis of situation.
• It suggests that before a change to take place there needs to be a
trigger to initiate the alteration.

46. • Social cognitive theory(Bandura): explains how individuals
initiate and maintain a given behaviour (i.e., quitting smoking) by
emphasizing the role of interactions among various cognitive,
environmental, and behavioural factors .
• Cognition: Various mental processes that occur within the
individual, such as behavioural capability, outcome expectancies,
emotional coping responses, and feelings of self-efficacy.
• Behavior: The manner in which the individual reacts to various
inputs from their social and/or physical environment (i.e., self-
regulation).

47. • Environment: Any factor physically external to the individual that
can impact one’s behaviour. The environment is comprised of social
factors (i.e., family, friends, observational learning), and physical
factors (i.e., weather, availability of tobacco products, etc.)
• Operant conditioning theory( Skinner): A rein forcer is any
situation or stimulus that strengthens a given response or behaviour
that precedes it.
• This helps to monitor their behaviour in order to identify and alter
the emotional and environmental cues that trigger the urge to smoke
along with the rein forcers that support the habit

48. PRIME theory:
• Nicotine from cigarettes generates the motivation to smoke and
undermines self-control by interacting with all of the level of
motivation.
• It creates stimulus-impulse associations resulting in cue-driven
urges; impairs inhibitory control; gives enjoyment resulting in
‘wanting’ to smoke; it leads to ‘nicotine hunger’, withdrawal
symptoms and beliefs about benefits of smoking (e.g. stress relief)
all of which can result in a ‘need’ to smoke.

49. • Understanding the multiple aspects of addiction requires an
understanding of human motivation.
• Many people conceptualise human motivation in terms of decisions
to do or not do things based on an analysis of their costs and
benefits
• However, it is clear that much behaviour is driven by habit or
instinct in which one just responds without thinking about the
consequences and often our actions are driven by feelings of desire
rather than judgements about what would be the best option.

50. • a model of human motivation that encapsulates these different
aspects of motivation In recent years, West and colleagues have
promoted the PRIME theory of motivation.
• This has been developed to overcome the deficits of previous
models.
• PRIME theory considers cigarette addiction to be a disorder of
motivation and it seeks, through a conceptualization of smokers’
plans, responses, impulses, motives, and evaluations to help
practitioners understand what they can do to help patients/clients
overcome their addiction

51. STRATEGIES FOR TOBACCO CESSATION - THE 5
“A”S AND 5 “R”S
• The Five A’s (Ask, Advise, Assess, Assist and Arrange)
• Five R’s (Relevance, Risk, Rewards, Repetitions, Roadblocks) is a
five to fifteen minute counseling approach that has proven global
success.

52. STEP 1: ASK
• Systematically identify all tobacco users at every visit.
• It should be an essential part of evaluation that for every tobacco
user at every consultation.
• Tobacco use status be queried and documented.

53. • STEP 2: ADVISE “STRONGLY URGE ALL TOBACCO
USERS TO QUIT”.
Advice should have:
1-Clear Message
2-Strong message
3- Personalized message

54. Tell them about benefits of quitting.
• BENEFITS OF QUITTING
• It is important to tell the tobacco user about the benefits of quitting.
• Begin thus - From the moment you quit smoking, it only takes 20
minutes for your body to start undergoing beneficial changes.

55. 20 Minutes:
• Blood pressure drops to normal; Pulse rate drops to normal;
Temperature of hands and feet increases to normal.
Within 8 Hours:
• Carbon-monoxide level in blood drops to normal; Oxygen level in
blood becomes normal.
Within 24 Hours to 48 hours:
• Chance of heart attack decreases.
• Ability to smell and taste begins to improve.

56. Within 72 hours:
• Bronchial tubes relax, making breathing easier.
Within 2 Weeks to 3 Months:
• Circulation improves. Lung function increases up to 30%
Within 6 Months:
• Coughing, sinus congestion, fatigue and shortness of breath
decrease. The lungs function better, as congestion reduces, so does
the chance of infection.

58. Within 1 Year:
• Risk of coronary heart disease decreases to half that of a smoker.
Within 10 Years:
• Risk of dying from lung cancer is reduced to half.
Within 15 Years:
• Risk of dying from a heart attack is equal to a person who never
smoked.

61. STEP 3: ASSESS
• Assess: Determine willingness to make a quit attempt.
• To be able to assist a tobacco user with tobacco cessation, assess his/
her willingness to commit to this change.
• Ask every tobacco user if he/she is willing to make a quit attempt at
this time (e.g. within the next 30 days)

63. • The stages of Readiness to change model is a valuable model for
assessing a tobacco user’s readiness to change the behaviour.
• Cessation is explained as a process, and tobacco users may go
through the steps of being ready, quitting and relapsing, an average
of three to four times, before achieving success.
• Tobacco users will be in different stages of readiness at different
times, hence, readiness needs to be re-evaluated constantly.

64. • The stages may be,
i ) Not ready (Pre contemplation)
ii) Unsure (Contemplation)
iii) Ready (Preparation)
iv) Action
v) Maintenance.

66. Assessment of nicotine dependence:
• Assess willingness to quit, and determine the level of Nicotine
addiction. This can be measured by Fagerstrom Scoring. The tool
has six simple questions. Scoring is done as followed:
1-A high level of addiction will rank between 7 and 10 points.
2-A medium level between 4 and 6 points.
3-A low level between 0 and 3 points.

68. STEP 4 – ASSIST
The following strategies are suggested to assist tobacco users in
motivational stage:
Help in making a QUIT PLAN:
Preparations for quitting;
1) Set a quit date; ideally, the quit date should be within 2 weeks.
2) Tell family, friends, and co-workers about quitting, plan and seek
their support.
3) Anticipate challenges to planned quit attempt, particularly during
the critical first few weeks. These include nicotine withdrawal
symptoms.
4) Remove tobacco products from surroundings.
5) Avoid – Avoid Smoking or Using tobacco in places where a lot of
time is spent e.g. work place. Avoid all forms of tobacco, do not
substitute one tobacco product for another.

69. • Provide practical counseling (Problem solving / skills training)
• Past quit experience-Identify what helped and what failed in
previous quit attempts.
• Anticipate triggers or challenges in upcoming attempt – Discuss
challenges and how user will successfully overcome them.
• Alcohol- The tobacco user should consider limiting/abstaining from
alcohol while quitting.
• Other tobacco users in household/ workplace.

70. • Provide intra treatment social support- supportive environment is
provided
• Help in obtaining extra treatment social support- provide help in
social support, ask spouse, friends to support you in your quit
attempt.
• Recommend Pharmacotherapy: Explain how the medications
improve success rates and reduce withdrawal symptoms.

71. PHARMACOTHERAPY
• Approved drugs for smoking cessation:
Nicotine replacement therapy (NRT)
• Nicotine gum, patch, lozenge, nasal spray, inhaler
NON - NRT
1-Psychotropics
• Sustained-release bupropion
2-Partial nicotinic receptor agonist
• Varenicline

72. NRT: PRODUCTS:
• Polacrilex gum
• Nicorette (OTC)
• Generic nicotine gum (OTC)
• Lozenge
• Nicorette Lozenge (OTC)
• Nicorette Mini Lozenge (OTC)
• Generic nicotine lozenge (OTC)
• Transdermal patch
• NicoDerm (OTC)
• Generic nicotine patches (OTC, Rx)
• Nasal spray
• Nicotrol NS (Rx)
• Inhaler
• Nicotrol (Rx)

73. NICOTINE GUM
• Resin complex
Nicotine
Polacrilin
• Sugar-free chewing gum base
• Contains buffering agents to enhance buccal absorption of nicotine
• Available : 2 mg, 4 mg
• Flavors :original, cinnamone, fruit, mint (various), and orange

74. NICOTINE LOZENGE
• Nicotine Polacrilex formulation
• Delivers 25% more nicotine than equivalent gum dose
• Sugar-free mint, cherry flavors
• Contains buffering agents to enhance buccal absorption of nicotine
• Available: 2 mg, 4 mg

75. TRANSDERMAL NICOTINE PATCH
• Nicotine is well absorbed across the skin
• Delivery to systemic circulation avoids hepatic first pass
metabolism
• Plasma nicotine levels are lower and fluctuate less than with
smoking

76. NICOTINE NASAL SPRAY
• Aqueous solution of nicotine in a 10-ml spray bottle
~100 doses/bottle
• Each metered dose actuation delivers
▫ 50 µL spray
▫ 0.5 mg nicotine
▫ Rapid absorption across nasal mucosa

77. NICOTINE INHALER
• Nicotine inhalation system consists of:
1-Mouthpiece
2-Cartridge with porous plug containing 10 mg nicotine and 1 mg
menthol
3-Delivers 4 mg nicotine vapor, absorbed across buccal mucosa

78. Dose and duration Side effects contraindications
1- nicotine
gum
1-24 cigarettes – 2 mg
gum(upto 24 pieces
/day)for 12 weeks
>25 cigarettes-4mg
gum(upto 24
pieces/day)for 12 weeks
Mouth soreness,
throat irritaton ,
dyspepsia, nausea,
vomiting
Gastric ulcers, MI or
stroke in past two
weeks
2-nicotine
patch
21 mg/24 hrs for 4
weeks then 15mg/24
hrs, 7mg/24hr for 2
weeks
Local skin
irritation, insomnia
MI or stroke in past
two weeks
3- nicotine
inhaler
6-16 cartridges/day for 6
months
Local irritation of
mouth and throat
As above
4-Nicotine
nasal spray
1-2 doses/hour 3 to 6
months
Nasal irritation,
irritation - of
throat, coughing
and watering of
As above

79. Non nicotine replacement therapy:
BUPROPION SR
• Oral formulation
• Atypical antidepressant that has both dopaminergic and adrenergic
actions.
• Quit date is set 7-14 days start of treatment.
• 150 mg OD for 3 days followed by 150 mg BD for 7-12 weeks
• Clinical effects
↓ craving for cigarettes
↓ symptoms of nicotine withdrawal
Side effects: agitation, restlessness, GI upset, anorexia
Contraindicated – history of allergy, undergoing alcohol withdrawal,
preganant and lactating women

80. VARENICLINE
• Partial nicotinic receptor agonist that binds to α and β nicotinic
acetylcholine receptors in brain
• Oral formulation 0.5 mg OD for first 3 days, increased to 0.5 mg
twice daily for next 4 days, 1 mg twice daily for 12 weeks.
• Clinical effects
↓ symptoms of nicotine withdrawal
• Tobacco use can be stopped one week after initiating treatment.
• Side effects: agitation, depression
• Contraindicated in pregnant and lactating women.

81. Combination Therapy:
• Combined behavioural and pharmacological therapies appear to be
the best approach for treating tobacco dependence.
• Because these therapies operate by different mechanisms,
complementary and potentially additive effects may be expected
• Nicotine Replacement Therapies (NRT) combined with supportive
counselling are the most widely used and intensively reached
treatment method

82. WITHDRAWAL SYMPTOMS:
• Commonly experienced withdrawal symptoms on stopping tobacco
use include:
Depressed mood
Insomnia
Irritability, frustration , anger
Anxiety
Craving and difficulty in concentration
Restlessness
Decreased heart rate
Increased appetite or weight gain

83. s

84. Non-Pharmacological Cessation Strategies:
• Tapering - Cut down the number of cigarettes/bidis smoked (or
smokeless tobacco) each day until the client finds they are no longer
using it.
• Cold Turkey - Abruptly stopping all smoking. Best for clients who
smoke two packs of cigarettes a day or less. Cold turkey is the
simplest and, for most people the easiest way to quit.

86. NOT WILLING TOQUIT
THE 5 “R”s APPROACH
• For tobacco users who are not ready to make a quit attempt, provide
a brief intervention designed to promote the motivation to quit and
information about harmful effect of tobacco.
• The tobacco user may have fears and concerns about quitting, or
may be demoralized because of previous unsuccessful attempts and
relapse.
• 5 “R”s; i.e. Relevance, Risk, Rewards, Roadblocks and Repetition.

87. Relevance:
• Encourage the tobacco user to consider the personal relevance of
cessation. Take into account the disease status (if any), family or
social situation, health concerns, age and gender.
Risks:
• Discuss risks of continued tobacco use, including effects of
exposure to second hand smoke on the family members especially
children. Relate with the symptoms.

88. Rewards:
• Encourage tobacco user to identify benefits of cessation.
Roadblocks:
• Barriers that the tobacco user may face in his/her quit attempt
should be identified.
• Withdrawal symptoms, fear and concern associated with quitting,
depression, lack of social support, enjoyment of tobacco are some of
the barriers that the tobacco user may face in an attempt.

89. • Repetition: This information should be reviewed regularly with
tobacco users who are not yet ready to quit. It is also important for
tobacco users who have not yet successfully quit to understand that
most people attempting cessation quit several time before finally
succeeding in quitting.

90. STEP 5: ARRANGE
• Arrange - Schedule a follow-up contact
• Time- Follow up contact should occur soon after the quit date,
preferably during the first week. A second follow up contact is
recommended within the first month.
• Follow up visits after advice to quit have been shown to increase the
likelihood to successful long term abstinence.
• During the follow up, quitters have some common problems and a
solution should be suggested accordingly.

93. Hypothesized Mediators of the Relation Between SES and
Smoking Cessation
• Social Support: Individuals of low SES report fewer close social
relationships and use their support network to a lesser extent than
individuals of higher SES
• Additionally, greater social support has consistently been shown to
have a positive influence on smoking cessation (Gulliver 1986)
• Social support may influence smoking cessation by increasing self-
efficacy(Gulliveretal.,1995;Sorensen,Barbeau,Hunt,& Emmons,
2004) and reducing negative affect/stress

94. • Neighborhood Disadvantage: Overall, individuals of lower SES
report greater exposure to neighborhood problems are more vigilant
for threat in their neighborhoods, and perceive less neighborhood
social cohesion than do those of higher SES.
• recent studies have indicated that neighborhood disadvantage is
associated with an increased likelihood of smoking and engaging in
other detrimental health behaviors (Ellaway & Macintyre, 2009)
Michael S. Businelle et al. Mechanisms Linking Socioeconomic Status to
Smoking Cessation: A Structural Equation Modeling Approach. Health
Psychology 2010, Vol. 29, No. 3, p.g.no 262–27.

95. • Negative Affect/Stress:
• Numerous studies have shown that negative affect and stress are
associated with both SES and smoking cessation
• Individuals of lower SES tend to report more stressors and greater
overall negative affect in relation to those of higher SES (Gallo &
Matthews, 2003)
• Agency: self-efficacy for quitting smoking has been linked to SES
and is an important predictor of smoking cessation.
• individuals with higher levels of education report higher confidence
in their ability to quit smoking.

96. • Craving:
• Although little is known about the relationship between SES and
craving, some research has shown that tobacco advertising is often
more prevalent in low-SES neighborhoods (Laws, Whitman,
Bowser, & Krech, 2002).
• It is possible that SES may have an indirect influence on nicotine
craving through exposure to tobacco advertisements.

97. Self help interventions for tobacco cessation:
• 1- minimal clinical intervention
• 2-intensive clinical intervention. This includes
a) Individual behavioural counselling
b) Supportive group sessions / group behaviour therapy
c) Aversion therapy
Others : 1-Telephone counselling
2- New technologies (txt2stop; txt2quit)

98. • Minimal clinical intervention: It is based on 5 ‘A’ approach.
• Brief advice/ intervention by health professionals.
• Involves in assessing their current tobacco use, advice them to stop,
offer assistance, referring to specialist
• Duration is 3-5 min
• Barrier for this procedure is lack of time, lack of skills & training.

99. • Intensive clinical intervention: More intensive behavioural
methods has been used to support patient attempts at smoking
cessation in clinical settings.
• Individual counselling: provided by specialist counsellors, not by
health care provider.
• Duration is 10 min.
• Review participants tobacco history, identifies high risk situation
and generates appropriate problem solving strategies.

100. • Supportive group sessions: Offers individuals to learn behavioural
techniques for tobacco cessation
• Led by professional facilitators, clinical psychologists, health
educators, nurses, doctors.
• It includes: sets up specific quit date.
• Learning to interrupt conditioned responses that support tobacco
• Make plans for coping with temptations to smoke following
cessation
• Provide follow up contact and social support.

101. • Aversion therapy: Adding an unpleasant stimulus to an attractive
behaviour reduces attractiveness and may extinguish behaviour.
• Rapid smoking is advised where they are asked to take puff for
every 6-10 sec for 3 min until they consume 3 cigarettes.
• Repeated 2-3 times and asked to concentrate on unpleasant
sensations it causes.
• Others: smoke holding, excessive smoking, behavioural treatment
with bitter pills.

102. Telephone counselling: They provide support and encouragement to
individuals who smoke and want to quit.
• Increased frequency of calls increases likelihood of person quitting
when compared with self help materials/ pharmacotherapy alone.
• Beneficial route for who may be time poor/ limited financially
resources.
New technologies: With the advent of smart phones, easy internet use
of text messaging( txt 2 stop, txt 2 quit) has been developed in
U.K,U.S.A
Lei Wu et al. Effectiveness of additional follow-up telephone counselling in a
smoking cessation clinic in Beijing and predictors of quitting among Chinese male
smokers . BMC Public Health (2016) 16:63

103. Smokeless tobacco and how to quit:
• Smokeless tobacco comes in 2 basic forms, snuff and chewing
tobacco.
Harmful health effects include:
• oral (mouth) cancer
• pancreatic cancer
• addiction to nicotine
• leukoplakia (white sores in the mouth that can become cancer)
• receding gums (gums slowly shrink away from around the teeth)
• bone loss around the roots of the teeth
• abrasion (scratching and wearing down) of teeth
• tooth loss
• stained teeth
• bad breath

104. Nicotine replacement therapy
• These include:
• nicotine gum
• nicotine patch
• nicotine lozenges
• nicotine inhaler
• nicotine nasal spray
Other medicines
• Bupropion
• Varenicline

105. Tobacco cessation in dental clinic:
• In the clinic ,dentists have an important role in helping patients quit
tobacco and, at the community and national levels, to promote
tobacco prevention and control strategies.
• Dentists in the clinic
• See the harmful effects of tobacco on the mouth Are in an ideal
position to counsel patients
• See children and youth as patients and can influence them to adopt
a tobacco-free lifestyle
• Treat women of childbearing age and can inform them of the
dangers of tobacco use during pregnancy

106. • 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.
• Dentists in the community and nation:
• Can be role models by not using tobacco or by quitting
successfully.
• Tobacco use by dentists is a significant barrier to tobacco cessation
counselling.
• Can speak with authority in the community about the dangers of
tobacco use

107. • 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 counselling.
• studies report that adolescents consistently rank physical
attractiveness, dental concerns, and oral health as greatly important

108. • Relating smoking to short-term adverse effects such as staining of
teeth, bad breath, loss of taste may be more relevant and meaningful
than relating smoking to long-term health effects such as
cardiovascular or lung diseases.
• Dentists should provide messages about tobacco use that are
appropriate to the patient's age and developmental stage.
• A congratulatory message positively reinforced can truly enhance
the chances of a child desisting from tobacco use in the future

109. Tobacco cessation at special situations:
• 1- pregnant and lactating women
• 2- Cardiovascular disease
• 3-people with smoking related disease
• 4-People with mental illness
• 5-People with substance-use disorders
• 6-Weight gain apprehensive patients
• Other therapies: Hypnosis, Acupuncture, Yoga

110. GLOBAL TOBACCO CONTROL
• Global Surveillance
• Framework Convention for Tobacco Control (FCTC)
• World Health Organization’s MPOWER Package

111. • Global Youth Tobacco Survey
• The purpose of the Global Youth Tobacco Survey (GYTS) is to
enhance countries’ capacity to monitor youth tobacco use, guide
national tobacco prevention and control programs, and facilitate
comparison of tobacco-related data at the national, regional, and
global levels.
• GYTS began in 1998 with a meeting between WHO and CDC,
which concluded that there was a need for surveillance of tobacco
use among adolescents 13-15 year old.
• The survey is been done using the core questionnaire consisting of
54 questions.

112. • Overall, 12 percent of boys currently smoke cigarettes and Overall,
nearly 7 percent of female students currently smoke cigarettes. The
rates are highest in the regions of Europe and Western Pacific, and
lowest in those of Eastern Mediterranean and South-East Asia.
• When asked for tobacco cessation 69% of current smokers would
like to stop the habit.

113. • The WHO Report on the Global Tobacco Epidemic, 2008 urges
countries to: “establish programmes providing low-cost, effective
treatment for tobacco users who want to escape their addiction.”
• Yet only nine high-income or middle-income countries, covering
only 5 percent of the world’s population, offer complete cessation
services to adults or youth. This leaves 95 percent of people without
access

115. • Global Health Professional Survey:
• WHO+ CDC+ Canadian public health association developed to
collect data on tobacco use and cessation counseling among health
professionals in all WHO member states.
• It included students of dentistry, medicine, nursing, pharmacy and
among them 3rd year students included.
• It uses core questionnaire

116. • Global School Personnel Survey:
• Data collected by the Global School Personnel Survey (GSPS)
between 2000 and 2008 have shown that an alarming proportion of
school personnel smoke cigarettes and use other forms of tobacco.
• About one-fifth of school teachers and administrators currently
smoke cigarettes.
• Twice as many male teachers as female teachers smoke cigarettes
and use other tobacco products.

117. • The majority of GSPS school personnel have not received specific
training to help students avoid or stop using tobacco, but strongly
agreed that they should receive training.
• Most teachers reported that they do not have adequate teaching
materials to support prevention and reduction in tobacco use.

118. • Global Adult Tobacco Survey (GATS)
• The Global Adult Tobacco Survey (GATS) is a nationally
representative household survey that was launched in February 2007
• It enables countries to collect data on adult tobacco use and key
tobacco control measures
• GATS has been implemented in more than 25 low- and middle-
income countries with highest burden of tobacco use.

119. Topics covered in GATS:
• Tobacco use prevalence (smoking and smokeless tobacco products).
• Second-hand tobacco smoke exposure and policies.
• Cessation.
• Knowledge, attitudes and perceptions.
• Exposure to media.
• Economics.

120. • Global Adult Tobacco Survey (GATS) India (2010) data revealed
that more than one out of three adults in India (35%) used tobacco
in some form or the other.
• Among them, 21 % of adults used only smokeless tobacco, 9% only
smoked and 5 % smoked as well as used smokeless tobacco.
• Overall tobacco use is much higher among Indian males at 48
percent but is also a serious concern among females among whom
prevalence is 20 per cent

121. Framework Convention on Tobacco Control (FCTC)
• The first international agreement on tobacco control, and the first
treaty ever negotiated by WHO.
• Developed in response to the globalization of the tobacco epidemic.
• Designed to promote national and global cooperation to counter the
worldwide tobacco epidemic.

122. Time line:
• May 1999: World Health Assembly called for work to begin
• May 2003: WHO’s 168 member states unanimously adopted the
treaty
• February 27, 2005: Treaty entered into force
• India is a signatory to FCTC and it joined in 2003.

123. Key Provisions of the FCTC
• Comprehensive bans on tobacco advertising, promotion, and
sponsorship within 5 years of ratification (some exceptions)
• Bans use of misleading and deceptive terms such as “light” and
“mild”
• Rotating health warnings required on packs that cover 30% or more
of the package and can include pictures or pictograms

124. • Protection from exposure to SHS in workplaces, public transport,
and indoor public spaces
• Encourages tobacco tax increases
• Prohibits sale to minors
• Strengthens legislation to combat smuggling
• Calls for testing, measuring, and regulating the contents and
emissions of tobacco products

125. WHO MPOWER Package
• 2008 Report –first in a series of WHO reports to track the status of
tobacco epidemic and impact of interventions
• Highlights global scope of the epidemic –“Tobacco is the single
most preventable cause of death in the world today.”
Six policies of WHO MPOWER package:
▫ Monitor tobacco use and prevention policies
▫ Protect people from tobacco smoke
▫ Offer help to quit tobacco use
▫ Warn about the dangers of tobacco
▫ Enforce bans on tobacco advertising, promotion and
sponsorship
▫ Raise taxes on tobacco

126. • WORLD NO TOBACCO DAY
• In 1987, WHO designated May 31 as World No Tobacco Day to
draw global attention to the health risks of tobacco use.
• Objective of celebrating the World No Tobacco Day all over the
world is
• to promote and encourage the common public to reduce or stop the
use of tobacco or its products consumption as it may lead to the
some lethal diseases (cancer, heart problem) or even death

127. • Various countries and tobacco cessation programmes:
• Seychelles: The country’s Tobacco Control Act of August 2009
created completely smoke-free environments in all enclosed public
places and workplaces, on all transport, and in selected outdoor
premises including all health and educational facilities
• Tobacco advertising, promotion and sponsorship are also
completely banned, formalizing the absence of tobacco advertising
that has been observed for several decades and extending it to new
forms of tobacco marketing.

128. • Comprehensive tobacco control legislation was first drafted in the
Seychelles in 1996 but it was passed in assembly in june 2009.
• Turkey: It began providing comprehensive tobacco dependence
treatment that includes a national quit line as well as coverage of
costs for nicotine replacement therapy and at least some other
cessation services.

129. • Phlippines: The Philippines has a strong and well-developed health
surveillance infrastructure
• National Nutrition and Health survey using the WHO STEPs
survey instrument shows that the Philippines’ tobacco use
monitoring system includes periodic, recent and representative
smoking prevalence data for both adults and youth, ranking the
country in the highest category of monitoring effectiveness.

131. • New zealand provides a wide range of free cessation services as
part of its comprehensive tobacco control strategy.
• New zealand first introduced nationally funded cessation
programmes in the late 1990s: a national quit line service
• The national quit line (http://www.quit.org.nz) now assists more
than 50,000 New zealanders each year who attempt to quit smoking
• Smoking prevalence among adults in 2009 was 21%, a decline by
about a third over the past two decades that resulted from sustained
strong tobacco control policies and high-quality cessation services.

132. Urguay
Mauritius

133. Turkey Russia
India

134. TOBACCO CONTROL IN INDIA
• Legislation for tobacco control started evolving in India in the mid-
1970s.
• This was in response to increasing scientific evidence of tobacco
being a major cause of mortality and morbidity in the world,
growing awareness of the adverse health effects of tobacco
consumption in India and rising demands for tobacco control
elsewhere in the world.

135. • 1975: Cigarettes (regulation of production, supply and distribution)
Act.
• 1980: Central and state governments imposed restrictions on
tobacco trade and initiated efforts for comprehensive legislation for
tobacco control.
• 1990: Central government issued directive prohibiting smoking in
public places, banned tobacco advertisements on national radio and
TV channels, advised state governments to discourage sale of
tobacco around educational institutions and extended the display of
statutory health warning to all chewing tobacco products.

136. • 1999: High Court of Kerala announced ban on smoking in public
places.
• 1999: Ministry of Railways banned sale of cigarettes and bidis on
railway platforms and in trains.
• 2000: Central government banned tobacco advertisements on cable
television.
• 2001: Supreme Court of India mandated a ban on smoking in public
places.
• In February 2001, Indian Prime Minister Vajpayee’s union cabinet
introduced Cigarettes and other Tobacco Products Bill.

137. • 2001: Ministry of Railways imposed ban on sale of gutkha (a
packaged chewing tobacco) in railway stations, inside trains and on
railway premises.
• 2001-2003: Production and sale of chewing tobacco products
banned in states of Tamil Nadu, Andhra Pradesh, Maharashtra,
Madhya Pradesh, Bihar and Goa using the provision of the
Prevention of Food Adulteration Act.
• 2002: tobacco cessation clinics were established for first time (13)
expanded to 19 now
• 2003: The Cigarettes and Other Tobacco Products (Prohibition of
Advertisement and Regulation of Trade and Commerce, Production,
Supply and Distribution) Act (COTPA), 2003 was introduced.

138. • 2003: India became a signatory to Framework Convention on
Tobacco Control (FCTC)—one of the first ten countries in the world
to do so.
• 2007: India defers pictorial health warning issue repeatedly. It is
now expected to be implemented from May 31st 2009.
• 2008: Revised smoke-free rules implemented that defined public
places and identified people responsible for maintaining smoke-free
work places. The government announced that all public places
across the entire country would go smoke-free.
• 2007-2008: Govt of India intiated National Tobacco control
programme

139. Training centres
• Training modules for doctors and health workers were also
developed in 2010-11 emphasizing the “brief advice” for tobacco
cessation.
• National Institute of Mental Health and Neurosciences
(NIMHANS) Bangalore offers a one month orientation course for
health professionals

140. • There a few known certified programs that are provided, one by
Directorate of Distance Education Annamalai University,
Tamilnadu, post graduate diploma program in health sciences
(Tobacco Control) (Annamalai University, 2011).
• The Public Health Foundation of India (PHFI), a public private
organization in collaboration with John Hopkins Bloomberg School
of Public Health and University of Southern California, USA has
introduced six month short term courses on tobacco control for
health professionals.

141. • For the first time, tobacco cessation was also incorporated in the
training modules of doctors under the Revised National
Tuberculosis Control Programme (RNTCP).

142. Role of Health Professionals
• One of the strategies to reduce morbidity and the number of
smoking-related deaths is to encourage the involvement of health
professionals in tobacco use prevention and cessation counselling
• Many studies have shown that counselling with a health
professional is an effective method of helping smokers quit
• GATS survey 2009-2010 revealed that who visited a health care
provider, 46.3% of smokers and 26.7% of users of smokeless
tobacco were advised to quit .

143. How Oral Health Professionals Can
contribute
• Dental care practitioners are a largely untapped resource for
providing advice and brief counselling to tobacco-using patients
• As dentists may see their patients on a frequent and recurring basis.
it is been suggested that dental personnel have unparalleled
opportunities to educate and help those who use tobacco to quit .
• Randomized clinical trials have found that even brief dental office-
based interventions can be effective in motivating and assisting
tobacco users to quit (Carr and Ebbert, 2006).

144. • Barriers: a number of studies have reported that delivery by health
care professionals is often suboptimal.
• The reasons are multiple but include time and service constraints
• Also, a key barrier is often that professionals have not had
appropriate training and and/or lack confidence in their own ability
to raise the issue of smoking cessation and provide appropriate
information and advice.

145. New Initiatives and Re-Direction of
The Old Initiatives
• 1-Incorporation of oral health into tobacco prevention policies
• 2-Integration of tobacco cessation techniques into group and
community settings
• 3-Setting up of 24 hour quit-lines
• 4-Setting up of tobacco cessation clinics at private dental
institutions through inclusion into dental curriculum
• 5-Team approach in tobacco cessation
• 6-Financial measures to discourage tobacco consumption

146. • 7-Tobacco awareness campaigning at school and colleges - Creating
Policies for a Tobacco-Free Campus
• 8-Extension of tobacco cessation services to the rural areas through
primary health care centres
• 9-Setting up of mobile oral health services with multidisciplinary
teams for people in the rural areas
Sukhvinder Singh Oberoi et al. Tobacco Cessation in India: How Can Oral Health
Professionals Contribute? Asian Pac J Cancer Prev, 15 (5), 2383-2391

147. Conclusion:
• Tobacco smoking remains a major contributor to premature
mortality and significantly adds to the global burden of disease and
disability.
• All professionals have a role in providing brief smoking cessation
advice and education. Support to prepare for and during a quit
attempt is best provided by health professionals with the appropriate
knowledge and skills.
• Health care providers need to work with people who smoke to
assist them in choosing the most helpful modality as a patient
centered approach to smoking cessation

148. References
• Burden Of Smoked And Smokeless Tobacco Consumption In India -
Results From The Global Adult Tobacco Survey India (GATS-
India)- 2009-2010.
• WHO Report On The Global Tobacco Epidemic, 2011
• Tobacco: Global Trends: ASH Research Report, 2011.
• History Of Tobacco 19th 20th 21st Century.
• Cigarette Smoke Components and Disease: Cigarette Smoke Is
More Thana Triad of Tar, Nicotine, and Carbon Monoxide, Smoking
and Tobacco Control Monograph No. 7, Chapter 5, p59-75.

149. • The War Against Tobacco, A Progress Report From The Indian
Front, The Economist Intelligence Unit 2009
• Tobacco Dependence Treatment Guidelines, National Tobacco
Control Programme, Directorate General of Health Services,
Ministry of Health and Family Welfare, Government of India.
• Training Manual Doctors, National Tobacco Control Programme,
Directorate General of Health Services, Ministry of Health and
Family Welfare, Government of India.
• World Health Organization, Regional Office for South-East Asia
Helping People Quit Tobacco: A Manual for Doctors and Dentists.
• ASH Research Report January 2012: Tobacco and Oral Health

150. • Addiction To Nicotine, WHO.
• Helping People Quit Tobacco: WHO Regional Office South East
Asia.
• Health Effects Of Tobacco, And Exposure To Tobacco Smoke
Nicotine, And Tobacco Smoke Pollution, Jonathan Foulds,
Handbook Of The Medical Consequences Of Alcohol And Drug
Abuse, 2008, Chapter 13.
• The Health Consequences Of Involuntary Exposure To Tobacco
Smoke A Report Of The Surgeon General.

151. • Ebbert J, Montori VM, Vickers-Douglas KS, Erwin PC, Dale LC,
Stead LF, Interventions for smokeless tobacco use cessation
(Review), The Cochrane Library 2009, Issue 1.
• Report on Tobacco Control in India, Ministry of Health & Family
Welfare, New Delhi, India
• Economic History Of Tobacco Production In India.
• Tobacco Cessation Services In India: Recent Developments And
The Need For Expansion Murthy P, Saddichha S, Indian Journal Of
Cancer ,2010, Volume 47, Suppl 1.