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Microsoft powerpoint - vajer.peter-smoking.cessation.ppt



Section 1: Burden of Disease Tobacco Dependence, Attitudes  Smoking is highly prevalent worldwide and Treatment Strategies  Smoking increases morbidity and mortality The benefits of quitting have been Department of Family Medicine Semmelweis University Gender-Specific Smoking Smoking Prevalence of Adults vs Prevalence Across the World Youths: Young People Are Also at Risk 1.25 billion smokers worldwide1-2 *Young men/women = 15-year-old students who smoke cigarettes.
1. Shafey O, et al (eds). Tobacco Control Country Profiles 2003, American Cancer Society, Atlanta, Georgia, 2003. Available at: http://www.who.int/tobacco/globaldata/countryprofiles/en/. 2. Mackay J, et al. The Tobacco Atlas. Second 1. Mackay J, et al. The Tobacco Atlas. Second Ed. American Cancer Society Myriad Editions Limited, Atlanta, Edition. American Cancer Society Myriad Editions Limited. Atlanta, Georgia, 2006. Also available online at: Georgia, 2006. Also available online at: http://www.myriadeditions.com/statmap/.
Smoking: Leading Preventable US Mortality From Smoking-Related Cause of Disease and Death1 Top 3 Smoking-Attributable Causes of Death in US #2 Ischemic heart disease Lung (#1)* Leukemia (AML, ALL, CLL)2-4 Pregnancy complications Lung, Trachea, Bronchus Cancer † Oral cavity/pharynx Laryngeal Reduced fertility Esophageal Stomach Sudden Infant Death Syndrome Ischemic Heart Disease † Pancreatic Kidney Respiratory Diseases Cerebrovascular Disease Ischemic heart disease (#2)* Adverse surgical outcomes/wound healing Stroke – Vascular dementia5 Peripheral vascular disease6 Abdominal aortic aneurysm Peptic ulcer disease† COPD (#3)*Pneumonia Poor asthma control Approximately 438,000 annual US deaths attributable to cigarette smoking *Top 3 smoking-attributable causes of death. †In patients who are Helicobacter pylori positive.
AML = Acute myeloid leukemia; ALL = acute lymphocytic leukemia; CLL = chronic lymphocytic leukemia; COPD = between 1997 and 2001 chronic obstructive pulmonary disease; SIDS = sudden infant death syndrome.
1. Surgeon General's Report. The Health Consequences of Smoking; 2004. 2. Sandler DP, et al. J Natl Cancer Inst. 1993;85(24):1994-2003. 3. Crane MM, et al. Cancer Epidemiol Biomarkers Prev. 1996;5(8):639- *Percentage of deaths attributable to specific smoking-related diseases, 1997–2001.
644. 4. Miligi L, et al. Am J Ind Med. 1999;36(1):60-69. 5. Roman GC. Cerebrovasc Dis. 2005;20(Suppl 2):91-100. 6. †Includes secondhand smoke deaths.
Willigendael EM, et al. J Vasc Surg. 2004;40:1158-1165.
1. CDC. MMWR. 2005;54:625–628.
Annual Deaths Attributable to Four Stages of the Tobacco Epidemic: Tobacco: Worldwide Estimates Mortality Is Increasing in Many Countries1 % of Total Deaths Attributable to Tobacco* Russian Federation • Eastern Europe • Western Europe, • Southern Europe • Southeast Asia • Latin America If current smoking patterns continue, deaths from smoking in Asia—home to a third of the world's population—are expected to increase by 2020 to 4.9 million annually.2 1. Lopez AD, et al. Tobacco Control. 1994;3:242-247. 2. Shafey O, et al (eds). Tobacco Control Country Profiles 2003, *Regional estimates in 2000 in men aged >35 years.
American Cancer Society; 2003; Atlanta, Georgia. Available at: 1. Mackay J, Eriksen M. The Tobacco Atlas. Second Ed. World Health Organization; 2006.
Smoking Reduces Survival an What's in a Cigarette? Average of 10 Years Results From a Study of Male Physician Smokers in the United Kingdom  Tobacco smoke: ≥4000 chemicals, ≥250 toxic or Chemical in Tobacco Smoke2 Physician Nonsmokers Physician Smokers Car exhaust fumes Industrial solvent  Nicotine is addictive, but not carcinogenic3  Smoking cigarettes with lower tar and nicotine provides no health benefit4 1. National Toxicology Program. 11th Report on Carcinogens; 2005. Available at: http://ntp-server.niehs.nih.gov. 2. Mackay J, Eriksen M. The Tobacco Atlas. World Health Organization; 2006. 3. Harvard Health Letter. May 2005. 4. 1. Doll R, et al. BMJ. 2004;328:1519–1527.
Surgeon General's Report. The Health Consequences of Smoking; 2004. Mechanisms of Action: What Does Secondhand Smoke Do? How Smoking Causes Disease  Estimated lung cancer risk increased by – Direct respiratory cell exposure to potent mutagens and carcinogens in tobacco smoke  Believed to cause and worsen diseases such as  Ischemic heart disease asthma, COPD, and emphysema2 – Toxic products in the bloodstream create a  Increases risk for developing heart disease by pro-atherogenic environment – Leads to endothelial injury and dysfunction,  Increases risk of nonfatal acute myocardial thrombosis, inflammation, and adverse lipid profiles infarction in a graded manner3  Chronic Obstructive Pulmonary Disease (COPD) – Accelerated decline in respiratory function 1. News release, June 27, 2006; US Department of Health & Human Services. Available at: http://www.hhs.gov/news/press/2006pres/20060627.html. 2. Mackay J, et al. The Tobacco Atlas. World Health 1. Surgeon General's Report. The Health Consequences of Smoking; 2004. Organization; 2002. 3. Teo KK, et al. Lancet. 2006;368:647-658.


What Does Secondhand Smoke Do Smoking During Pregnancy to Infants and Children?  Almost 60% of US children are exposed to secondhand smoke1  Exposure during pregnancy associated with1–3  In some countries, ≥80% of youth live in homes where others smoke – Increased risk of miscarriage, stillbirth, sudden infant in their presence2 death syndrome (SIDS); eg  Secondhand smoke increases disease burden and hospitalisation in infants and children. For example: – Low-birth weight – UK - 17,000 children under the age of 5 years hospitalised annually3 • 4-fold risk1: eg, 9700–18,600 cases related to secondhand – Australia - 56% higher risk for hospitalisation if mother smoked in same smoke annually in US*3 room as infant, 73% if smoked while holding infant, and 95% if smoked – Impaired infant lung function2 while feeding infant (N = 4486)4 – Hong Kong - higher likelihood for hospitalisation for infants living with – Possible association with cognitive and any smoker at home with poor smoking hygiene (<3 metres away)5 1. Secondhand smoke; Fact sheet, June 2006. Available at: http://www.cdc.gov/tobacco/factsheets/secondhand_smoke_factsheet.htm. 2. Mackay J, Eriksen M. The Tobacco 1. Fagerström K. Drugs. 2002;62(Suppl 2):1–9. 2. Le Souef PN. Thorax. 2000;55:1063–1067. Atlas. World Health Organization; 2006. 3. Fagerstrom K. Drugs. 2002;62(suppl 2):1-9. 4. Blizzard L, et al. Arch 3. Mackay J, et al. The Tobacco Atlas. World Health Organization; 2002. 4. Hellstrom-Lindahl E, Pediatr Adolesc Med. 2004;158:687-693. 5. Leung GM, et al. Arch Pediatr Adolesc Med. 2004;158:687-693.
et al. Respiration. 2002;69:289-293.
Importance of NOT Smoking Why Quit? Potential Lifetime Health Benefits of Quitting Smoking Cardiovascular heart disease (CHD) risk is similar to never smokers Rate of Infants with Low-Birth Weight Lung cancer risk is 30-50% that of continuing smokers in Taiwanese Infants by Smoking Status of the Mother (N=9499) Stroke risk returns to the level of people who have never smoked at 5-15 years post-cessation CHD: excess risk is reduced by 50% Lung function may start to improve with decreased cough, sinus congestion, fatigue, and shortness of Rate of Infants With Low Birth Weight Never Smoked Quit Smoking‡ 1. CDC. Surgeon General Report 2004: http://www.cdc.gov/tobacco/sgr/sgr_2004/sgranimation/flash/index.html. American Cancer Society. Guide to Quitting Smoking. Available at: http://www.cancer.org. Accessed June 2006. 2. American Cancer Society. Guide to Quitting Smoking. Available at: http://www.cancer.org. Accessed June 2006. 3.US Department of Health & Human Services. The Health Benefits of Smoking Cessation: A Report of the Surgeon †P<0.05 vs never smoked. ‡Before or during first trimester.
General. Centers for Disease Control and Prevention (CDC), Office on Smoking and Health. 1990. Available at: 1. Wen CP, et al. Tob Control. 2005;14(Suppl 1):i56–i61.
http://profiles.nlm.nih.gov/NN/B/B/C/T/. Accessed July 2006. Quitting at Any Age May Increase Quitting at Any Age May Increase Results From a Study of Male Physician Smokers in the United Kingdom Results From a Study of Male Physician Smokers in the United Kingdom Stopped Age 55-64 Stopped Age 45-54 Cigarette Smokers Cigarette Smokers 1. Doll R, et al. BMJ. 2004;328:1519–1527.
1. Doll R, et al. BMJ. 2004;328:1519–1527.





Quitting at Any Age May Increase Risk of Cardiovascular Disease (CVD) Reduced By Quitting Smoking Results From a Study of Male Physician Smokers in the United Kingdom Stopped Age 35-44 Cigarette Smokers  Quitting associated with – 36% reduction in odds of all-cause mortality among patients with coronary heart disease (CHD)1 – Decreases in CVD events in cardiac patients, even in those who  Quitting sooner appears most beneficial *Defined as self-reported smokers who were cotinine negative.
1. Doll R, et al. BMJ. 2004;328:1519–1527.
1. Critchley JA, Capewell S. JAMA. 2003;290:86-97. 2. Twardella D et al. Eur Heart J. 2004;25:2101–2108.
Mechanism of Action of Nicotine in the Central Nervous System Tobacco Dependence and Treatment Strategies Nicotinic Receptor Nicotine binds preferentially to nicotinic acetylcholinergic (nACh) receptors in the central nervous system; the primary is the α4β2 nicotinic receptor in the Ventral Tegmental Area (VTA) After nicotine binds to the α4β2 nicotinic receptor in the VTA, it results in a release of dopamine in the Nucleus Accumbens (nAcc) which is believed to be linked to reward Nicotine Stimulates Dopamine Nicotine May Cause Up-Regulation and Desensitization of Receptors Resulting in  Nicotine activates α4β2 nicotinic receptors in the ventral  Tolerance typically develops after long-term nicotine use1 tegmental area resulting in dopamine release at the  Tolerance is related to both the up-regulation (increased number) nucleus accumbens. This may result in the short-term and the desensitization of nicotine receptors in the VTA1 reward/satisfaction associated with cigarette smoking.
 A drop in nicotine level, in combination with the up-regulation and decreased sensitivity of the nicotinic receptor, can result in withdrawal symptoms and cravings1  Smokers have the ability to self regulate nicotine intake by the frequency of cigarette consumption and the intensity of inhalation1  In order to maintain a steady nicotine level, smokers generally titrate their smoking to achieve maximal stimulation and avoid symptoms of withdrawal and craving2 − α4β2 Nicotinic Receptor Adapted from Picciotto MR, et al. Nicotine and Tob Res. 1999: Suppl 2:S121-S125.
1. Schroeder SA. JAMA. 2005;294:482-487. 2. Jarvis MJ. BMJ. 2004; 328:277-279.
The Cycle of Nicotine Addiction So Why Do People Smoke?  Nicotine binding causes an increase in Addiction – Habitual psychological and physiological dependence release of Dopamine1,2 on substance or practice which is beyond voluntary control  Dopamine gives feelings of pleasure – Stedman's Medical Dictionary  The Dopamine decrease between  Since at least the 1988 Surgeon General's Report1 cigarettes leads to withdrawal symptoms of irritability and stress1 – Addiction defined as compulsive use despite damage to the  The smoker craves Nicotine to release individual or society and drug-seeking behavior can take more Dopamine to restore pleasure precedence over important priorities – Addiction persists despite a desire to quit or even repeated  Competitive binding of Nicotine to nicotinic acetylcholinergic receptors causes prolonged activation,  Most people smoke primarily because they are addicted desensitization, and upregulation2  As Nicotine levels decrease, receptors revert to an open state causing  There is a clear link between smoking, nicotinic hyperexcitability leading to cravings1,2 receptors, and addiction2 1. Centers for Disease Control and Prevention. The Health Consequences of Smoking: Nicotine Addiction; A Report of the Surgeon General. Washington DC: US Department of Health and Human Services; 1988. 1. Jarvis MJ. BMJ. 2004; 328:277-279. 2. Picciotto MR, et al. Nicotine and Tob Res. 1999: Suppl 2:S121-S125.
2. Jarvis MJ. BMJ. 2004;328:277-279. Nicotine Addiction: A Chronic Tobacco Dependence and Environmental Relapsing Medical Condition Behavior Reinforcement  True drug addiction1 Requires long-term clinical intervention, as do other addictive  Pharmacologic effects – Nicotine is a primary reinforcer – Failure to appreciate the chronic nature of nicotine addiction  Non-pharmacologic effects • Impair clinicians' motivation to treat tobacco dependence long-term – Environmental/social stimuli associated with smoking • Impede acceptance that condition is comparable to diabetes, play a role in reinforcing nicotine dependence hypertension, or hyperlipidemia, and requires counseling, support, and appropriate pharmacotherapy – Environmental/social stimuli enhance the reinforcing effects of nicotine – The nature of addiction, not the failure of the individual3 Direct pharmacologic effects of nicotine are necessary but not • Long-term smoking abstinence in those who try to quit unaided† = 3%–5% sufficient to explain tobacco dependence; these effects • Most relapse within the first 8 days must take into account the environmental/social context in which the behavior occurs 1. Fiore MC, Bailey WC, Cohen SJ, et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence. US Department of Health and Human Services. Public Health Service; June 2000. Available at: www.surgeongeneral.gov/tobacco/default.htm. 2. Jarvis MJ. Why people smoke. BMJ. 2004;328:277-279.
1. Caggiula AR et al. Psychol Behavior. 2002;77:683–687.
Withdrawal Syndrome: a Combination of Why Some Smokers May Need More Physical and Psychological Conditions, Making Smoking Hard to Treat1,2 Withdrawal Syndrome  Studies show some groups may be less frustration, or anger – Higher level of dependence1 Increased appetite • Cigarettes per day (may increase or • Time to first cigarette upon awakening with quitting)1,2 – Living with a current smoker1 – Fewer educational qualifications2 – Lower socioeconomic class2 Difficulty concentrating – Co-morbid psychiatric disorders3 1. Diagnostic and Statistical Manual of Mental Disorders, IV-TR. Washington, DC: APA; 2006: Available at http://psychiatryonline.com. Accessed November 7, 2006. 2. West RW, et al. Fast Facts: Smoking Cessation. 1st ed. 1. Hyland A et al. Nicotine Tob Res. 2004;6(Suppl 3):S363-S369. 2. Chandola T et al. Addiction. 2004;99:770-777. Oxford, United Kingdom. Health Press Limited. 2004.
3. Kalman D et al. Am J Addict. 2005;14:106–123.
Multiple Quit Attempts Most Smokers Are Willing to  More than 70% of US smokers have attempted to quit1  Of smokers who relapsed following a quit – Approximately 46% try to quit each year – Less than 5% who try to quit are abstinent 1 year later – 98% were willing to try again – Similar percentages in countries with established tobacco control programs (eg, Australia, Canada, UK)2 – 50% immediately • 30% to 50% try to quit; <5% achieve long-term abstinence – 28% within 1 month  Some smokers succeed after making several attempts3  Of those willing to try again immediately – Past failure does not prevent future success – Percentage did not differ based on time since – Length of prior abstinence is related to quitting success  Some smokers may prefer a waiting period before attempting to quit again 1. Fiore MC, et al. US Department of Health and Human Services. Public Health Service. June 2000. 2. Foulds J, et al. Expert Opin Emerg Drugs. 2004;9:39–53. 3. Grandes G, et al. Br J Gen Pract. 2003;53:101–107. 1. Joseph A, et al. Nicotine Tob Res. 2004;6:1075–1077.
Length of Prior Abstinence Is Related to Quitting Success Advice and Support  Previous quit attempts of ≥ 3 months  All smokers should be1 positively predicted sustained, – Advised to quit (the "5As") – Offered assistance irrespective of motivation biochemically confirmed abstinence1  Three types of non-pharmacologic therapies are – N = 1768; OR* = 1.8; 95% CI = 1.1–2.7 – Practical counseling (problem solving/skills training)  Duration of previous quit attempts – Social support as part of treatment influenced continuous abstinence at 6 – Securing social support outside of treatment  Effectiveness increases with treatment intensity1,2 – N = 509; OR* = 1.73; 95% CI = 1.09–2.75 1. Fiore MC, et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence. US Department of Health and Human Services. Public Health Service; June 2000. Available at: www.surgeongeneral.gov/tobacco/default.htm. *OR = odds ratio.
2. National Institute for Health and Clinical Excellence. Brief interventions and referral for smoking cessation in 1. Grandes G et al. Br J Gen Pract. 2003;53:101–107. 2. Aubin HJ et al. Addiction. 2004;99:1206-1218.
primary care. Available at: www.nice.org.uk/page.aspx?o=299611. Accessed September 2006.
Tobacco Dependence Support: The "5As": Ask About Tobacco Use  Identify and document tobacco use status for  Ask about tobacco use every patient at every visit  Implement an office-wide system that ensures  Assess willingness to make a quit attempt tobacco-use status is queried and documented  Assist in quit attempt – Expand vital sign documentation to include tobacco  Arrange follow-up – Tobacco-use stickers on charts – Computer reminder systems for electronic medical 1. Fiore MC, et al. US Department of Health and Human Services. Public Health Service. June 2000.
1. Fiore MC, et al. US Department of Health and Human Services. Public Health Service. June 2000.
The "5As": Assess Willingness to The "5As": Advise to Quit Make a Quit Attempt  In a clear, strong, and personalized manner, urge every tobacco user to quit at least once per year  Is the tobacco user willing to make a quit attempt • "I think it is important for you to quit smoking now, and I can help – If patient is willing to attempt quitting, offer assistance – If patient is unwilling to quit now, provide motivational • "As your clinician, I need you to know that quitting smoking is very important to protecting your health now and in the future." • Tie tobacco use to health/illness (reason for office visit), social/economic costs, motivation level, and impact on others (children) 1. Fiore MC, et al. US Department of Health and Human Services. Public Health Service. June 2000.
1. Fiore MC, et al. US Department of Health and Human Services. Public Health Service. June 2000.
The "5As": Assist in Quit Attempt The "5As": Arrange Follow-up  For the patient willing to make a quit attempt, use  Schedule follow-up contact, preferably within the first counseling and pharmacotherapy week after the quit date – Provide practical counseling (problem solving and skills training)  Follow-up can occur either in person or via telephone – Provide social support  Follow-up actions – Offer pharmacotherapy as appropriate – Congratulate success – Provide supplementary materials – Review circumstances of lapse – elicit recommitment to • World Health Organization: www.who.int • Centers for Disease Control and Prevention: www.cdc.gov/tobacco – Identify and anticipate challenges • Society for Research on Nicotine and Tobacco: www.srnt.org – Assess pharmacotherapy use – Consider need for referral to formal program – Consider referral for more intensive treatment • Telephone or internet-based 1. Fiore MC, et al. US Department of Health and Human Services. Public Health Service. June 2000.
1. Fiore MC, et al. US Department of Health and Human Services. Public Health Service. June 2000.
Patient Satisfaction Linked With Effectiveness Increases with "5A" Interventions Treatment Intensity  Regardless of readiness to quit, smokers receiving 5A interventions were more satisfied with their health care Minimal Counseling 13.4 (10.9, 16.1) (less than 3 minutes) Low Intensity Counseling 16.0 (12.8, 19.2) (3 to 10 minutes) Higher Intensity Counseling 22.1 (19.4, 24.7) (more than 10 minutes) Very Satisfied (%) N=1160. *P<0.0001; †P= 0.0014.
1. Fiore MC, et al. Clinical Practice Guideline: Treating Tobacco Use and Dependence. US Department of Health and 1. Conroy MB, et al. Nicotine Tob Research 2005;7(Suppl 1):S29–S34.
Human Services. Public Health Service; June 2000. Available at: www.surgeongeneral.gov/tobacco/default.htm. Pharmacotherapy for Tobacco for Smoking Cessation  Nicotine replacement therapy (NRT)1 – Long acting1-3 Physician advice1 Brief vs no advice (usual care) 1.74 (1.48–2.05) Intensive vs minimal advice 1.44 (1.24–1.67) – Short acting1-3 Individual counseling2 Vs minimal behavior intervention 1.56 (1.32–1.84) Group counseling3 2.04 (1.60–2.60) Vs no intervention 2.17 (1.37–3.45) • Sublingual tablets/lozenges Proactive Telephone counseling4  Antidepressants4 Vs less intensive interventions 1.56 (1.38–1.77) – Bupropion SR4 Vs no intervention 1.24 (1.07–1.45) – Nortriptyline3 (not approved for smoking cessation) *Abstinence assessed at least 6-months following intervention.
1. Lancaster T, Stead LF. Cochrane Database Syst Rev. 2004;(4):CD000165. 2. Lancaster T, Stead LF. Cochrane Database Syst Rev. 2005;(2):CD001292. 3. Stead LF, Lancaster T. Cochrane Database Syst Rev. 2005;(4): 1. Silagy C, et al. Cochrane Database Syst Rev. 2004;(3):CD000146. 2. Stead L, et al. Int J Epidemiol. CD001007. 4. Stead LF et al. Cochrane Database Syst Rev. 2005;(4):CD002850. 5. Lancaster T, Stead LF. Cochrane 2005;34:1001–1003. 3. Henningfield JE, et al. CA Cancer J Clin. 2005;55:281-299. Database Syst Rev. 2005;(3):CD001118. 4. Hughes JR et al. Cochrane Database Syst Rev. 2004;(4):CD000031. Nicotine Replacement Therapy (NRT): Nicotine Nicotine Replacement Therapy (NRT) Delivery by Cigarettes and NRT Products Cigarette (nicotine delivery, 1-2 mg) Gum (nicotine delivery, 4 mg) – NRT has been shown to be safe and effective in Nasal spray (nicotine delivery, 1 mg) helping people stop using cigarettes when used as Transdermal patch part of a comprehensive smoking cessation program1  Delivers nicotine that binds to the nAChR  Does not generally counter the additional satisfaction from smoking1  NRTs may not deliver nicotine to the circulation as fast as smoking2 80 90 100 110 120 Time post-administration (minutes) 1. American Heart Association website: http://www.americanheart.org/presenter.jhtml?identifier=4615, accessed November 5, 2006. 2. Sweeney CT, et al. CNS Drugs. 2001;15:453-467.
1. Sweeney CT, et al. CNS Drugs. 2001;15:453-467.
Efficacy of Nicotine Replacement Bupropion SR (Zyban®)  ZYBAN (bupropion SR hydrochloride) is a non- nicotine sustained-release tablet for smoking 1.66 (1.52–1.81)  Initially developed as an antidepressant, later 1.81 (1.63–2.02) found to have efficacy in smoking cessation1 2.35 (1.63–3.38)  There are 2 potential MOAs: 2.14 (1.44–3.18) – Blocks reuptake of dopamine2,3– Non-competitive inhibition of α3β2 and α4β2 nicotine 2.05 (1.62–2.59) Combination vs single type 1.42 (1.14–1.76) Any NRT vs control 1.77 (1.66–1.88) 1. Package Insert. bupropion SR hydrocloride [Zyban®]. GlaxoSmithKline. 2. Henningfield JE, et al. CA Cancer J Clin. 1. Silagy C et al. Cochrane Database Syst Rev. 2004;(3):CD000146. 2. Stead L, Lancaster T. Int J Epidemiol. 2005;55:281–299. 3. Foulds J, et al. Expert Opin Emerg Drugs. 2004;9:39–53. 4. Slemmer JE, et al. J Pharmacol Exp Ther. 2000;295:321–327. 5. Roddy E. Br Med J. 2004;328:509–511.


Comparison of Nicotine Replacement Therapy (NRT) Champix (varenicline): A Highly and Bupropion SR Therapy for Quitting Smoking1 Selective α4β2 Receptor Partial Agonist  Only study comparing NRT and antidepressant therapy for quitting smoking2 Placebo (n = 160) Nicotine Patch (n = 244) Bupropion SR (n = 244) Bupropion SR + Patch (n = 245) Binding of nicotine at the α4β2 nicotinic receptor Champix is an α4β2 nicotinic receptor partial agonist, in the VTA is believed to cause release of a compound with dual agonist and antagonist dopamine at the nAcc activities. This is believed to result in both a lesser amount of dopamine release from the VTA at the nAcc as well as the prevention of nicotine binding at 1 Year Continuous Abstinence the α4β2 receptors.
(Week 2 to Week 52) 1. Coe JW et al. Presented at the 11th Annual Meeting and 7th European Conference of the Society for Research on *P ≤ 0.001 vs placebo and patch alone.
Nicotine and Tobacco. 2005. Prague, Czech Republic. 2. Picciotto MR et al. Nicotine Tob Res. 1999; Suppl 2:S121- 1. Jorenby DE, et al. N Engl J Med. 1999;340:685–691. 2. Talwar A et al. Med Clin North Am. 2004;88:1517–1534.
Varenicline Mechanism of Action: 1: Findings from the STOP survey Efficacy for Tobacco Dependence  Efficacy of varenicline in tobacco dependence Other things have higher priority – Believed to result from partial agonist activity at the α4β2 nicotinic receptor Helping patient stop is part of job  By preventing binding of nicotine, varenicline – Reduces craving and withdrawal symptoms (agonist activity) Stopping is primarily down to willpower – Produces a reduction of the rewarding and reinforcing effects of smoking (antagonist activity) Smoking is addictive  The most frequently reported adverse events (>10%) Smoking is a medical condition with varenicline were nausea, headache, insomnia, and abnormal dreams. Smoking is a lifestyle choice Pfizer-sponsored survey: Interviews with 2836 smoking and non-smoking general practitioners in 16 countries 1. Champix Summary of Product Characteristics. Pfizer Ltd, Sandwich, UK. 2006.
1: Apparent paradoxes 1: What does this mean? Smoking is an addiction stopping is a matter of Need a message that recognises the duality of beliefs about smoking Smoking should be is primarily a lifestyle "Smokers must take responsibility for regarded as a medical stopping smoking, and they will need determination to succeed; but when determination is not enough, the Helping patients to stop other things have a physician has effective tools to help the is part of the job 2: A simple model of nicotine 2: The process of stopping Chronic intake of Motivational tension When smokers think about their smoking most, they are unhappy about it, but many 1. Think it meets certain needs 2. Is a source of enjoyment 3. Think stopping will be difficult controlling motivation Something needs to prompt them to make a quit attempt using a method that maximises their chances of success A biologically driven Cues associated with Experience of relief of nicotine withdrawal The treatment needs to be of a type and when nicotine levels symptoms leads to intensity that meets the individual smoker's in the brain are low expectations of more needs, and available whenever and for as long as the smoker needs it 3: The physician's role 3: A simple consultation model Yes, I know I should Every month you put off • To give professional, expert stopping, you may lose another advice on health matters week off your life • To provide treatment to those You have to question whether it is worth the pain and suffering who want and need it you will endure later Now is not a good time Now is always a good time for stopping, smoking doesn't really • Now is a good time to stop • It is always worth having I am worried that Most smokers make many attempts before they succeed to a clear, firm • There are things available that Addictions can be conquered, will make it easier especially when you get help It's never too late…

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HEALTH CARE BENEFITS IN CANADA March 2006 We Take a Closer Look Wendy Murkar Vice-President, Claims Administration Green Shield Canada ƒ State of health care in Canadaƒ Issues affecting benefit utilization ƒ Impact on benefit plan design STATE OF HEALTH CARE IN CANADA Benchmarking of

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20th International Congress for Analytical Psychology; Kyoto, August 28 to September 2, 2016 Pre-Congress Workshop on Authentic Movement: Danced and Moving Active Imagination ANIMA MUNDI IN TRANSITION: Cultural, Clinical, And Professional Challenges (English) Psyche is as much a living body as body is living psyche.