Smoking Cessation

0
National Guidelines on Smoking Cessation

NATIONAL GUIDELINES ON
SMOKING CESSATION
CLINICAL PRACTICE GUIDELINES ON TREATMENT OF TOBACCO
USE AND DEPENDENCE 2009
Endorsed by:
Mns!ry o" #e$%!&' (or%d #e$%!& Or)$n*$!on' P$+s!$n C&es! So,e!y' P$+s!$n C$rd$, So,e!y- #y.er!enson %e$)/e
$nd C$n,er So,e!y-
1
CONTENTS
Foreword..02
Message from WHO Pakistan..03
Preface..04
Introduction...05
nti !o"acco #aws in Pakistan0$
%ifferent forms of to"acco in use & t'eir 'ea(t' conse)uences...*0
!o"acco %e+endence ......*2
,(inica( Inter-entions For !o"acco .se nd %e+endence..*4
,ounse(ing a +atient.22
WHO/0 +ackage for contro((ing to"acco e+idemic.....25
P'armacot'era+1 for to"acco cessation...22
++endi3 *. 0ummar1 of 0moking ,essation Inter-entions...34
++endi3 2. How to assess !o"acco %e+endence...34
++endi3 3. 0mokers/ fre)uent(1 asked )uestions and t'eir answers.3$
5eferences42
2
FORE(ORD
!o"acco is t'e sing(e most common +re-enta"(e cause of deat' in t'e wor(d toda1 6*7. In t'e 20t' centur18
more t'an *00 mi((ion +eo+(e died wor(dwide due to use of to"acco and to"acco re(ated +roducts. !'is
figure is estimated to rise to one "i((ion during t'is centur1 627. !'e a-erage (oss of (ife in smokers is *5
1ears. For t'ose w'o die in midd(e age8 t'e a-erage (oss is as muc' as 22 1ears 637. "out 'a(f of a((
regu(ar smokers are e-entua((1 ki((ed "1 smoking.
ccording to t'e WHO 200$ re+ort8 32.49 adu(t men and 5.2 9 adu(t women are current to"acco:users
in Pakistan. #ung cancer is t'e num"er one cause of deat's due to cancer in Pakistani ma(es and o-er
;09 of t'em are caused "1 smoking 647. !'ese figures are a(arming(1 'ig' and we need to take urgent
measures in order to sa-e t'ese 'uman (i-es.
!'e Hea(t' Ministr1 recogni<es t'e need for doctors and ot'er 'ea(t' +rofessiona(s to +artici+ate in t'e
smoking cessation +rogram. Hea(t'care +rofessiona(s can +(a1 an acti-e ro(e in 'e(+ing smokers to )uit
smoking. "rief ad-ice of on(1 a few minutes from t'e doctor8 su++orted "1 educationa( materia(8 'as
"een s'own to ac'ie-e to"acco:)uitting rates of u+ to 59 657.
nti:to"acco +o(icies and +rograms 'a-e "een s'own to increase t'e num"er of smokers attem+ting to
)uit. 0moke:free areas8 +u"(ic 'ea(t' cam+aigns and t'e ro(e of 'ea(t'care +rofessiona(s are t'e +riorit1
+o(ic1 de-e(o+ment areas identified to su++ort t'is issue.
Most im+ortant(18 co((a"oration is needed "etween go-ernment & 'ea(t'care +rofessiona( organi<ations to
esta"(is' and +romote guide(ines and +o(icies t'at encourage 'ea(t'care +rofessiona(s to take a more
acti-e ro(e in t'e treatment of !o"acco %e+endence. .nfortunate(18 t'ere 'a-e "een no guide(ines for t'e
'ea(t' care +rofessiona(s in t'is regard. !'ese ,(inica( Practice =uide(ines are t'e first of its kind8 meant
to assist doctors and ot'er 'ea(t' +rofessiona(s to 'e(+ smokers get rid of to"acco use for good.
Dr R$s&d 0/1$
%irector =enera( of Hea(t'
Ministr1 of Hea(t'
3
Mess$)e "ro1 (#O P$+s!$n
Dr K&$%" B%e Mo&$1/d
(#O P$+s!$n
4
PREFACE
Tobacco use can kill in so may ways that it is a risk factor for six of the
eight leading causes of death in the world.
Margaret Chan Fung Fu-Chun, Director General WHO 2008
!o"acco use is one of t'e ma>or causes of +remature and +re-enta"(e deat's in our countr1. It is estimated
t'at a++ro3imate(1 *008000 deat's in Pakistan are attri"uted to to"acco use e-er1 1ear. Howe-er des+ite
t'e 'ig' +re-a(ence of to"acco use8 t'e 'ea(t'care +ro-iders are not we(( trained to manage t'is +ro"(em
effecti-e(1. Hea(t' +rofessiona(s need to rea(i<e t'at treating to"acco de+endence is muc' more cost:
effecti-e t'an treating diseases caused "1 to"acco use.
!'e o">ecti-e of t'is guide(ine is to +ro-ide t'e (atest and u+dated treatment +rotoco(s to assist 'ea(t' care
+ro-iders in managing to"acco use and de+endence effecti-e(1.
!'e +re(iminar1 draft of t'e guide(ine was re-iewed "1 e3+erts from -arious medica( fie(ds re(e-ant to
to"acco cessation. !'ese inc(ude (eading c'est +'1sicians8 cardio(ogists8 ?@! s+ecia(ists and cancer
s+ecia(ists. !'e1 a(( co((a"orated and re-iewed -arious (oca( and internationa( materia(s to +roduce t'is
document.
It is 'o+ed t'at c(inicians and a(( ot'er a((ied 'ea(t'care +ro-iders wi(( fo((ow t'is e-idence:"ased
guide(ine to ma3imi<e t'e success rate of to"acco cessation. Howe-er8 t'is guide(ine is not meant as a
su"stitute for c(inica( >udgment and c(inicians are recommended to indi-idua(i<e t'eir treatment strategies.
!'is guide(ine is +(anned for a re-iew at an e-er1 two:1ear inter-a( "1 t'e committee and a++ro+riate
u+dates if t'e need arises.
Dr 0$2$d K&$n FRCP 3Edn4
Head 0ection of Pu(monar1 and ,ritica( ,are Medicine
!'e ga A'an .ni-ersit1 Aarac'i
,'airman 0moking ,essation =uide(ine ,ommittee8 Pakistan ,'est 0ociet1
O!&er Me1bers:
*. %r Muk'tiar BamanCPes'awer
2. %r Mo'ammad DusufC Pes'awer
3. %r 0aadia s'rafC Pes'awer
4. %r ,o( Wa>id (iC Is(ama"ad
5. %r 0'ireen A'anC Euetta
4. %r Mu'ammad Irfan Aarac'i
5
INTRODUCTION
Tobacco is the only legally available consumer product
which kills people when it is used entirely as intended.
(The Oxor! Me!ical Co"#anion,
O3fordF O3ford .ni-ersit1 Press8 *;;4$
G%ob$% S!/$!on
!o"acco use is t'e (eading +re-enta"(e cause of deat' in t'e wor(d 6*7. In t'e 20t' centur18 more t'an *00
mi((ion +eo+(e died wor(dwide due to use of to"acco and to"acco re(ated +roducts8 wit' 209 of t'ese
deat's occurring in de-e(o+ing countries. !'is 1ear8 to"acco wi(( ki(( more t'an fi-e mi((ion +eo+(e G
more t'an tu"ercu(osis8 HIHII%0 and ma(aria com"ined. J1 20308 t'e deat' to(( wi(( e3ceed eig't
mi((ion a 1ear. Moreo-er8 un(ess urgent action is taken8 to"acco cou(d ki(( one "i((ion +eo+(e during t'is
centur1 627. !'ose w'o smoke 20 cigarettesIda1 are 25 times more (ike(1 to die of (ung cancer as
com+ared to nonGsmokers. Wor(d Hea(t' Organi<ation 6WHO7 estimates t'at 429 men and *29 women
smoke g(o"a((1. In de-e(o+ed countries8 429 men and 249 women are smokers8 w'ereas in de-e(o+ing
countries8 4$9 men and 29 women are smokers. !o"acco use is a risk factor for si3 of t'e eig't (eading
causes of deat' in t'e wor(d inc(usi-e of isc'emic 'eart disease8 cere"ro-ascu(ar disease8 (ower
res+irator1 infections8 ,OP%8 tu"ercu(osis8 and trac'ea and "ronc'us (ung cancers 627.
!o"acco and its re(ated +roducts 'a-e +(a1ed 'a-oc wit' 'uman (i-es around t'e g(o"e. !'e destruction
caused "1 to"acco o-er t'e 1ears is 'uge and it 'as now turned into an Ke+idemic/8 as t'e num"er of
+eo+(e d1ing is e3+onentia((1 increasing. Howe-er8 t'e to"acco e+idemic is +re-enta"(e. One can "e a "it
o+timistic t'at 'undreds of mi((ions of +eo+(e do not 'a-e to die from to"acco:re(ated i((ness G "ut on(1 if
t'e (eaders of go-ernments and t'e ci-i( societ1 take urgent action now. #eaders around t'e g(o"e need to
recogni<e t'at to"acco use can and must "e confronted and sto++ed.
6
Adapted from: WHO 2008 Repot on Glo!al "o!a##o $pidemi#
S!/$!on n P$+s!$n
In most de-e(o+ed countries t'e +re-a(ence of smoking is on t'e dec(ine and so are to"acco
re(ated deat's from (ung cancer8 'eart attacks and ot'er diseases 6*7. .nfortunate(1 to"acco use is
on t'e increase in de-e(o+ing countries (ike Pakistan. Man1 transnationa( to"acco com+anies
find Pakistan8 a countr1 wit' o-er *40 mi((ion +eo+(e8 an idea( +(ace to +romote t'eir to"acco
"usiness. In t'e @ationa( Hea(t' 0ur-e1 of *;;4 among adu(ts 349 of ma(es and ;9 of fema(es
were found to "e smokers 627.
If we inc(ude t'e use of to"acco in ot'er forms 6smoke:(ess to"acco7 suc' as #aan8 gut%a an!
na&'ar, t'en t'e true +re-a(ence of to"acco users is muc' 'ig'er.
Mainstreaming to"acco contro( into t'e +u"(ic 'ea(t' agenda is a "ig c'a((enge. !'is is due to t'e
fact t'at to"acco industr1 contri"utes 40 "i((ion 5u+eesL in ta3es to t'e nationa( e3c'e)uer and
+ro-ides em+(o1ment and "usiness o++ortunities to more t'an *.2 mi((ion +eo+(e a(( o-er t'e
countr1.
One of t'e "iggest c'a((enges for t'e countr1 in to"acco contro( is t'e 'ig' +re-a(ence of
smoking amongst t'e medica( doctors. In one of t'e sur-e1s done at a ma>or teac'ing 'os+ita( of
Aarac'i8 32 9 of ma(e 'ouse officers were found to "e regu(ar smokers 647. !'e w'o(e
credi"i(it1 of t'e anti:to"acco message is (ost if t'e +u"(ic sees a doctor smoking. %octors a(so
need to "e trained on smoking cessation ski((s. Most medica( sc'oo( curricu(a do not teac'
to"acco as a se+arate su">ect in s+ite of t'e fact t'at t'is +owerfu( addicti-e su"stance is
res+onsi"(e for 'undreds of +re-enta"(e diseases.
stud1 conducted in Aarac'i 6Pakistan7 re-ea(ed t'at t'e +re-a(ence of smoking among medica(
students was a(arming(1 'ig' i.e. 22.09 of ma(e and 3.$9 of fema(e medica( students were current
%
smokersC a(t'oug' ma>orit1 of t'em did recogni<e t'e dangers associated wit' acti-e as we(( as +assi-e
smoking 627. !'e +re-a(ence of ado(escent fema(es w'o 'ad tried smoking at (east once in t'eir (ife 6i.e.
Me-er:smokersN7 was found to "e *4.39 and t'e mean age of smokers was *5.2; 1rs 6$7.
.se of smoke(ess to"acco in -arious forms is a(so -er1 'ig' in Pakistan. recent stud1 'as s'own t'at
2*.59 of students 'a-e used to"acco in some form 6smoked or smoke(ess7 in t'eir (ifetime. @aswar was
t'e most common(1 used form of smoke(ess to"acco fo((owed "1 +aan and nass 6;7.
!o"acco associated cancers in Aarac'i were res+onsi"(e for 3$.39 of tumors diagnosed in ma(es. #ung
cancer was t'e most fre)uent(1 encountered cancer in ma(es fo((owed "1 cancer of t'e ora( ca-it1. In
fema(es8 "reast and ora( ca-it1 cancers are res+onsi"(e for 409 of cancers in Aarac'i 647.
8
ANTI5TOBACCO LA(S IN PAKISTAN
In 20028 t'e +resident of Pakistan im+(emented an ordinance "1 t'e name of Prohibition of Smoking in
Enclosed Places and Protection of on!smokers "ealth #rdinance$ %&&%( ccording to t'is ordinanceF
*. @o +erson can smoke or use to"acco in an1 +(ace of +u"(ic work or use.
2. @o +erson can smoke or use to"acco in an1 ot'er form in an1 +u"(ic ser-ice -e'ic(e.
3. @o +ersonsI com+anies can ad-ertise to"acco and to"acco +roducts on an1 media8 in an1 +(ace or
in an1 +u"(ic ser-ice -e'ic(e8 if suc' ad-ertisement is not in accordance wit' guide(ines
+rescri"ed for t'is +ur+ose "1 a committee formu(ated "1 t'e Federa( =o-ernment.
4. @o +erson can se(( cigarettes8 or an1 ot'er suc' smoking su"stance to an1 one w'o is "e(ow t'e
age of eig'teen 1ears.
5. @o +erson can 'imse(f or "1 an1 +erson on 'is "e'a(f8 store8 se(( or distri"ute cigarettes or an1
ot'er suc' smoking su"stance wit'in an area of 50 meters from an1 co((ege8 sc'oo( or educationa(
institution.
4. !'e owner or manager or in c'arge of t'e affairs of e-er1 +(ace of +u"(ic work or use8 s'a((
dis+(a1 and e3'i"it a "oard at a cons+icuous +(ace in and outside t'e +remises -isited or used "1
genera( +u"(ic +rominent(1 stating t'at t'e +(ace is a O@o 0moking BoneO and t'at O0moking is an
OffenceO.
2. n1 +erson8 w'o -io(ates t'e (aw8 wou(d "e +unis'a"(e wit' a fine w'ic' ma1 e3tend from one to
fi-e t'ousand ru+ees and in case of second or su"se)uent offence8 wou(d "e +unis'a"(e wit' a
fine w'ic' s'a(( not "e (ess t'an one 'undred t'ousand ru+ees or wit' im+risonment w'ic' ma1
e3tend to t'ree mont's8 or wit' "ot'.
Howe-er unfortunate(18 none of t'ese (aws are im+(emented in t'e true s+irit. !'at/s w'1 t'e "urden of
to"acco usage in our countr1 is e-er increasing.
&
Key G/de%ne Re,o11end$!ons
!'e o-erarc'ing goa( of t'ese recommendations is t'at c(inicians strong(1 em+(o1 t'e use of effecti-e
to"acco de+endence counse(ing and medication treatments to t'eir +atients w'o use to"acco.
*. !o"acco de+endence is a c'ronic disease t'at often re)uires re+eated inter-ention and mu(ti+(e attem+ts
to )uit. ?ffecti-e treatments e3ist8 'owe-er8 t'at can significant(1 increase rates of (ong:term a"stinence.
2. It is essentia( t'at c(inicians and 'ea(t' care de(i-er1 s1stems consistent(1 identif1 and document
to"acco use status and treat e-er1 to"acco user seen in a 'ea(t' care setting.
3. !o"acco de+endence treatments are effecti-e across a "road range of +o+u(ations. ,(inicians s'ou(d
encourage e-er1 +atient wi((ing to make a )uit attem+t to use t'e counse(ing treatments and medications
recommended in t'is =uide(ine.
4. Jrief to"acco de+endence treatment is effecti-e. ,(inicians s'ou(d offer e-er1 +atient w'o uses to"acco
at (east t'e "rief treatments s'own to "e effecti-e in t'is =uide(ine.
5. Indi-idua(8 grou+8 and te(e+'one counse(ing are effecti-e8 and t'eir effecti-eness increases wit'
treatment intensit1. !wo com+onents of counse(ing are es+ecia((1 effecti-e8 and c(inicians s'ou(d use
t'ese w'en counse(ing +atients making a )uit attem+tF
P Practica( counse(ing 6+ro"(em so(-ingIski((s training7
P 0ocia( su++ort de(i-ered as +art of treatment
4. @umerous effecti-e medications are a-ai(a"(e for to"acco de+endence8 and c(inicians s'ou(d encourage
t'eir use "1 a(( +atients attem+ting to )uit smokingQe3ce+t w'en medica((1 contraindicated or wit'
s+ecific +o+u(ations for w'ic' t'ere is insufficient e-idence of effecti-eness 6i.e.8 +regnant women8
smoke(ess to"acco users8 (ig't smokers8 and ado(escents7.
P !'ree first:(ine medications re(ia"(1 increase (ong:term smoking a"stinence ratesF
G Ju+ro+ion 05
G @icotine gum
G @icotine +atc'
G Harenic(ine
P ,(inicians a(so s'ou(d consider t'e use of certain com"inations of medications identified as effecti-e in
t'is =uide(ine.
2. ,ounse(ing and medications are effecti-e w'en used "1 t'emse(-es for treating to"acco de+endence.
!'e com"ination of counse(ing and medication8 'owe-er8 is more effecti-e t'an eit'er a(one. !'us8
c(inicians s'ou(d encourage a(( indi-idua(s making a )uit attem+t to use "ot' counse(ing and medication.
$. If a to"acco user current(1 is unwi((ing to make a )uit attem+t8 c(inicians s'ou(d use t'e moti-ationa(
treatments s'own in t'is =uide(ine to "e effecti-e in increasing future )uit attem+ts.
10
DIFFERENT FORMS OF TOBACCO IN USE 6
T#EIR #EALT# CONSE7UENCES
'n the %&th century$ the tobacco epidemic killed (&& million people
worldwide. )uring the %(
st
century$ it could kill one billion.
(WHO re#ort on the glo)al to)acco e#i!e"ic, 2008$
(t'oug' standard cigarettes are t'e most common(1 used t1+e of smoked to"acco8 ot'er smoked to"acco
+roducts8 suc' as "idis8 kreteks8 @aswar 6snuff7 and s'is'a8 are gaining +o+u(arit1 G often in t'e mistaken
"e(ief t'at t'e1 are (ess 'a<ardous to 'ea(t'. Howe-er8 a(( forms of to"acco are (et'a( 6*07. 0moked
to"acco in an1 form causes u+ to ;09 of a(( (ung cancers and is a significant risk factor for strokes and
fata( 'eart attacks 6**7.
Jidis8 sma(( 'and:ro((ed cigarettes are t1+ica((1 smoked in 0ind' and +art of Pun>a" and ot'er sout':?ast
sian countries. !'e1 +roduce t'ree times more car"on mono3ide and nicotine8 and fi-e times more tar
t'an regu(ar cigarettes 6*27. Jidi smokers 'a-e a t'ree:fo(d 'ig'er risk of ora( cancer com+ared wit' non:
smokers and are a(so at increased risk of (ung8 stomac' and eso+'agea( cancer.
0'is'a 6to"acco mi3ed wit' f(a-orings and smoked from 'ooka's7 is +o+u(ar in t'e ?astern
Mediterranean region. recent stud1 from Aarac'i s'owed t'at s'is'a use is gaining +o+u(arit1 amongst
t'e 1out' of t'e cit1 6*37. It is a(so (inked to (ung disease8 cardio-ascu(ar disease and cancer 6*07.
S1o+e%ess !ob$,,o
O-er one:t'ird of to"acco consumed in 0out' sia is smoke(ess. !raditiona( forms (ike "ete( )uid8
to"acco wit' (ime and to"acco toot' +owder are common(1 used and t'e use of new +roducts is
increasing8 not on(1 among men "ut a(so among c'i(dren8 teenagers8 women of re+roducti-e age8 and
e-en medica( and denta( students. Ora( su" mucous fi"rosis is increasing due to t'e use of +rocessed areca
nut +roducts8 man1 containing to"acco. Pregnant women in India w'o use smoke(ess to"acco 'a-e a
t'reefo(d increased risk of sti(("irt' and a two: to t'reefo(d increased risk of 'a-ing a (ow "irt' weig't
infant. In recent 1ears8 se-era( states in India 'a-e "anned t'e sa(e8 manufacture and storage of gutka8 a
smoke(ess to"acco +roduct containing areca nut.
Pre-a(ence of use of c'ewa"(e +roducts is 'ig' in Pakistan8 wit' +articu(ar(1 'ig' use of certain
su"stances re(ati-e to certain socio:demogra+'ic +rofi(es. Industria((1 +re+ared +roducts8 c'aa(ia and
gutka8 are gaining +o+u(arit1 among t'e 1out'. Po(icies and focused inter-entions can "e de-e(o+ed
taking into consideration t'e +referred use of +roducts among different socio:demogra+'ic grou+s.
!'e +re-a(ence of use of smoke(ess to"acco +roducts was 'ig'er t'an cigarettes among 'ig':sc'oo(
students 6*4.*9 -ersus *3.297 and t'e age at starting use of smoke(ess to"acco was a(so (ower t'an for
cigarettes 6mean **.5 1ears -ersus *3.* 1ears7. 0e-era( factors ma1 contri"ute to t'e use of smoke(ess
to"accoF it is eas1 to o"tain8 is more socia((1 and cu(tura((1 acce+ta"(e t'an cigarettes and easier to use
t'an smoked +roducts8 es+ecia((1 in t'e sc'oo( en-ironment w'ere smoking restrictions are enforced.
11
Parenta( sanctions are a(so not -er1 'ig' for t'e use of smoke(ess to"acco "ecause of t'e con-iction of
man1 +eo+(e t'at smoke(ess to"acco +oses a (ower 'ea(t' risk t'an cigarettes. d-ice to sto+ smoke(ess
to"acco cou+(ed wit' "e'a-iora( su++ort and counse(ing ma1 increase (ong:term a"stinence rates "1
5:*09. !'ere is insufficient e-idence at +resent to recommend t'e use of nicotine re+(acement t'era+18
"u+ro+ion or -arnic(ine to aid smoke(ess to"acco cessation 6*47.
Se,ond5&$nd8 P$ss2e S1o+n)
0mokers are not t'e on(1 ones +rone to sickness and deat' "1 to"acco. It must "e noted t'at "reat'ing
second'and smoke is e)ui-a(ent to smoking i.e. !wo 'ours in a smok1 office e)ua(s to smoking four
cigarettes8 two 'ours in a nonsmoking section of restaurant e)ua(s to smoking two cigarettes8 and (i-ing
toget'er wit' a +ack:a:da1 smoker for 24 'rs means smoking at (east t'ree cigarettes. 0econd:'and
smoke a(so 'as serious and often fata( 'ea(t' conse)uences. In t'e .nited 0tates8 second:'and smoke
causes a"out 38400 (ung cancer deat's and 448000 'eart disease deat's a 1ear. 0econd:'and smoke is
res+onsi"(e in t'e .nited 0tates for an estimated 430 cases of sudden infant deat' s1ndrome8 248500 (ow:
"irt':weig't "a"ies8 2*8;00 +re:term de(i-eries and 2008000 e+isodes of c'i(d'ood ast'ma annua((1 6*57.
0ome of t'e common diseases caused "1 second:'and smoke in c'i(dren inc(ude "rain tumors8 midd(e ear
disease8 (1m+'oma8 im+aired (ung function8 ast'ma8 sudden infant deat' s1ndrome8 (eukemia8 and (ower
res+irator1 i((ness. %iseases (ike stroke8 nasa( sinus cancer8 coronar1 'eart disease8 (ung cancer8
at'erosc(erosis8 ,OP%8 ast'ma8 +re:term de(i-er1 & (ow "irt' weig't "a"ies are common in adu(ts due to
second:'and smoke 6*47.
In addition to t'e 'ea(t' conse)uences of second:'and smoke8 it is a(so a serious drain on economic
resources around t'e wor(d. For e3am+(e8 second:'and smoke e3+osure in t'e .nited 0tates a(one costs
an estimated .0R 5 "i((ion annua((1 in direct medica( costs and more t'an .0R 5 "i((ion more in indirect
medica( costs suc' as disa"i(it1 and (ost wages 6*27. In t'e Hong Aong 0+ecia( dministrati-e 5egion of
,'ina8 t'e cost of direct medica( care8 (ong:term care and +roducti-it1 (osses due to second:'and smoke
e3+osure is a++ro3imate(1 .0R *54 mi((ion annua((1 6*$7.
!'e economic (osses faced "1 Pakistan "ecause of smoking are tremendous. Jased on a stud1 done "1
(am 0? et a( in *;;$ 6*;78 Pakistan was facing a (oss of more t'an 542 Mi((ion ru+ees dai(1 "ecause of
t'e use of to"acco. !'is (oss is e3+ected to "e muc' 'ig'er now considering t'e increase in t'e +re-a(ence
of smoking and increase in t'e +rice of cigarettes.
In Pakistan8 to"acco is res+onsi"(e for ;09 of #ung ,ancers8 ;09 of ,OP%8 409 of o-era(( cancers 6207
and 20 ot'er fata( diseases. !'e (ist of diseases caused "1 smoking is 'uge and a(( t'e detai(s cannot "e
co-ered 'ere. Howe-er8 some of t'e common diseases caused "1 smoking inc(ude stroke8 "(indness8
cataract8 coronar1 'eart disease8 +neumonia8 at'erosc(erotic +eri+'era( -ascu(ar disease8 ,OP%8 ast'ma8
'i+ fractures8 reduced ferti(it1 and cancers of t'e (ar1n38 eso+'agus8 trac'ea8 (ung8 stomac'8 +ancreas8
kidne18 ureter8 co(on8 cer-i38 "(adder etc 62*7.
It must "e noted 'ere t'at to"acco:re(ated diseases usua((1 do not "ecome e-ident for 1ears or decades
after to"acco use is started. Pakistan is one of t'ose countries t'at are sti(( in t'e ear(1 stages of t'e
Mto"acco e+idemicN8 so we 'a-e 1et to e3+erience t'e fu(( im+act of to"acco re(ated diseases and deat's
a(read1 e-ident in wea(t'ier countries w'ere to"acco use 'as "een common for muc' of t'e +ast centur1.
12
TOBACCO DEPENDENCE
!o"acco smoke contains a++ro3imate(1 48000 different constituents8 inc(uding to3ic su"stances suc' as
carcinogens 6@:nitrosamines8 aromatic '1drocar"ons78 ammonia8 nitrogen o3ide8 '1drogen c1anide8 ,O
and nicotine 6207.
!o"acco de+endence can "e defined as **a clu&ter o )eha+ioral, cogniti+e an! #h,&iological #heno"ena
that !e+elo# ater re#eate! u&e an! t,#icall, inclu!e a &trong !e&ire to &"o%e, !iicult, in controlling it&
u&e, #er&i&ting in it& u&e !e&#ite har"ul con&e-uence&, increa&e! tolerance to nicotine, an! a (#h,&ical$
'ith!ra'al &tate..6227.
%e+endence on to"acco is a com+(e3 "e'a-iour8 wit' "ot' en-ironmenta( and genetic inf(uences 6237.
@icotine is t'e main com+onent in cigarettes t'at contri"utes to addiction. It acts on s+ecific nicotinic
acet1(c'o(ine rece+tors in t'e "rain8 stimu(ating t'e re(ease of do+amine t'at is "e(ie-ed to "e associated
wit' t'e acute rewarding effect of nicotine 6247. Moreo-er8 c'ronic smoking (eads to an u+ regu(ation of
nicotine rece+tors.
13
Bene"!s o" S!o..n) S1o+n)
0to++ing smoking is t'e "est t'ing t'at a +erson can do to im+ro-e t'eir current and future 'ea(t'.
!'e ear(ier a +erson can sto+ t'e "etter. Howe-er8 it is ne-er too (ate to sto+. Peo+(e w'o sto+ smoking
'a-eF
P a reduced risk of d1ing ear(1
P a reduced risk of de-e(o+ing (ung cancer
P a reduced risk of coronar1 'eart disease and stroke
P a reduced risk of d1ing from c'ronic "ronc'itis and em+'1sema
P im+ro-ement in res+irator1 s1m+toms8 suc' as coug' and s'ortness of "reat'
P reduced risks of ot'er cancers re(ated to smoking 6for e3am+(e8 cancers of u++er res+irator1 tract8
eso+'agus8 "(adder and +ancreas7
P reduced risks of com+(ications in +regnanc1 and c'i(d"irt' 6for e3am+(e8 +(acenta +re-ia and
+(acenta( a"ru+tion7
P im+ro-ement in some menta( 'ea(t' s1m+toms
P fewer sick da1s off work
P im+ro-ement in reco-er1 from surger1 and reduced +erio+erati-e risk
P a re-ersa( of t'e risks of smoking if cessation is ac'ie-ed "1 t'e age of 35.
0to++ing smoking wi(( a(soF
P set a good e3am+(e for c'i(dren and 1oung +eo+(e 6c'i(dren of non:smokers are (ess (ike(1 to
"ecome regu(ar smokers7
P im+ro-e t'e 'ea(t' of 1oung c'i(dren of +arents w'o 'a-e ceased smoking
P sa-e mone1.
Ado.!ed "ro1: /e' 0ealan! 1"o%ing Ce&&ation Gui!eline&. Ministr1 of Hea(t'. 2002( We((ingtonF
Ministr1 of Hea(t'.
14
CLINICAL INTER9ENTIONS FOR TOBACCO USE
AND DEPENDENCE
(&$! ,$n $ &e$%!& .ro"esson$% do:
%o not smoke or use to"acco
!ake a 'istor1 of smokingIto"acco use
=i-e firm ad-ice to +atient w'o uses to"acco
#earn M'ow to counse( a +atientN in order to make t'em )uit smokingIto"acco use
?ducate t'e +u"(ic regarding t'e 'a<ards of acti-e & +assi-e smoking and ot'er forms of to"acco
use
T&e ; A<s A..ro$,&
15
16
do+ted fromC Fiore M,8 Saen ,58 Jaker !J8 et a(. Treating To)acco 2&e an! De#en!ence3
2008 2#!ate( ,(inica( Practice =uide(ine. 5ock-i((e8 M%F ..0. %e+artment of Hea(t' and Human
0er-ices. Pu"(ic Hea(t' 0er-ice. Ma1 200$.
1%
18
do+ted from C Fiore M,8 Saen ,58 Jaker !J8 et a(. Treating To)acco 2&e an! De#en!ence3
1&
20
21
22
A%)or!&1 "or !re$!n) !ob$,,o /se
23
COUNSELING A PATIENT
,ounse(ing a to"acco user to )uit to"acco is an art w'ic' e-er1 'ea(t' +rofessiona( s'ou(d tr1 to (earn.
Patients addicted to to"acco and w'o wis' to )uit must "e made c(ear rig't at t'e -er1 "eginning t'at
to"acco smokingInicotine addiction is more (ike a c'ronic8 recurrent disorder wit' an e3+ected successfu(
cessation rate after treatment of *5G359 after * 1r8 simi(ar to ot'er addicti-e disorders. 0e-era( fai(ed
cessation attem+ts ma1 occur "efore +ermanent a"stinence is ac'ie-ed. More im+ortant(18 e-en if a
smoker is a"(e to sto+ smoking and to"acco use8 nicotine addiction remains +resent for man1 1ears as
s'own "1 re(a+se in e3:users.
N,o!ne (!&dr$=$% sy1.!o1s
Patients s'ou(d "e e3+(ained t'at a++ro3imate(1 4:*2 ' after )uitting smoking8 -ar1ing degrees of
@icotine wit'drawa( s1m+toms "egin to a++ear. !'ese ma1 inc(ude irrita"i(it18 an3iet18 ner-ousness8
rest(essness8 de+ressed mood8 difficu(t1 concentrating8 cra-ing for cigarettes8 increased a++etite and s(ee+
distur"ance. 01m+toms often +eak wit'in a week and t'en dec(ine o-er se-era( weeks to mont's 6258 247.
Weig't ma1 increase "1 2G3 kg during t'e first 3 mont's after cessation of smoking. !'e +atient s'ou(d
"e -er1 c(ear(1 to(d t'at t'ese s1m+toms are tem+orar1 and wi(( go awa1.
#ast8 "ut not t'e (eastC it is -er1 im+ortant t'at t'e doctor gi-es t'e rig't message w'i(e 'e counse(s t'e
+atient a"out )uitting to"acco use. For e3am+(e8 a midd(e aged ,OP% "reat'(ess +atient s'ou(d "e to(d
t'at 'is disease is main(1 "ecause of to"acco use and if 'e )uits smoking not on(1 'is "reat'ing wi(( "e
easier "ut it wi(( a(so 'e(+ im+ro-e 'is )ua(it1 of (ife. smoker8 on t'e ot'er 'and8 w'o "rings 'is c'i(d
wit' an ast'ma attack8 s'ou(d "e to(d t'at one of t'e im+ortant triggering agents for 'is c'i(d/s ast'ma
e3acer"ations is smoking. For a midd(e:aged (ad1 w'o uses to"acco8 t'e re(e-ant message cou(d "e t'at if
s'e )uits smoking8 s'e wi(( 'a-e reduced wrink(ing of skin.
Howe-er8 des+ite t'e counse(ing8 it is -er1 common to see smokers w'o sto++ed for )uite a w'i(e "ut
s(i++ed "ack into smoking and t'en )uit again and t'en s(i++ed "ack again8 and t'e c1c(e continues.
5esearc' suggests t'at +eo+(e w'o smoke go t'roug' a fi-e stage to"acco addiction c1c(e t'at (eads t'em
from "eing non:smokers to new smokers8 t'en to committed smokers8 to smokers tr1ing to sto+ and to
fina((18 reformed smokers 6227.
Bene"!s o" >/!!n) S1o+n)
!'e +atient s'ou(d "e gi-en incenti-es and e3+(ained reasons w'1 )uitting smoking is so im+ortant. For
e3am+(e8 fo((owing are some of t'e "enefits w'ic' a 'ea(t' +rofessiona( can te(( t'e +atient w'i(e
counse(ing a"out )uitting smoking.
Dou wi(( (i-e (onger and "etter and 'a-e reduced wrink(ing I aging of skin.
Euitting wi(( (ower 1our c'ance of 'a-ing a 'eart attack8 stroke or cancer and im+ro-e 1our
'ea(t'.
24
Dou wi(( 'a-e e3tra mone1 to s+end on t'ings ot'er t'an cigarettes
Food wi(( taste "etter and 1ou wi(( 'a-e an im+ro-ed sense of sme((.
Dou wi(( "e a"(e to sa-e mone1.
Dou wi(( fee( "etter a"out 1ourse(f and +erform "etter at +'1sica( acti-ities.
Dou can sto+ worr1ing a"out )uitting.
Dou set a good e3am+(e for c'i(dren.
Dou wi(( 'a-e 'ea(t'ier "a"ies and c'i(dren.
Dou wi(( not 'a-e to worr1 a"out e3+osing ot'ers to smoke.
Modes o" ,o/nse%n)
Bre" Ad2,e
Jrief ad-ice "1 a +'1sician or nurse (asting as (itt(e as (ess t'an t'ree minutes 'as "een s'own to "e
effecti-e in making +eo+(e )uit smoking. !'is is done on a one:on:one "asis and if a smoking cessation
(eaf(et is a(so gi-en at t'e time of t'is ad-ice t'en it can increase t'e )uit rate. !'ere is a strong dose:
res+onse re(ations'i+ "etween session (engt' or +erson to +erson contact and successfu( treatment
outcome. Intensi-e inter-entions are certain(1 more effecti-e t'an "rief ad-ice.
Gro/. Co/nse%n)
=rou+ t'era+1 a((ows more +eo+(e to "e treated "1 one e3+ert and cou(d "e more cause effecti-e t'an
indi-idua( counse(ing.
Te%e.&one Co/nse%n)
!e(e+'one counse(ing can "e +roacti-e or reacti-e. In t'e +roacti-e a++roac' t'e e3+ert initiates t'e ca((
to +ro-ide t'e smoker wit' su++ort to make a )uit attem+t. Proacti-e counse(ing is +ro-ided -ia a 'e(+
(ine t'at takes ca((s from t'e smoker. !'ere is a )uit smoking ser-ice a-ai(a"(e in Pakistan in w'ic' a
+s1c'o(ogist w'o is an e3+ert on smoking cessation is a-ai(a"(e during working 'ours to take (i-e ca((s
from smokers w'o want to )uit smoking 60$00 IE.I!7. Euit (ines can "e a++ea(ing to t'ose +atients w'o
are uncomforta"(e discussing t'eir smoking in a grou+Qand it/s free to t'e +atient'
(eb5b$sed .ro)r$1s on !&e In!erne!
25
#ike )uit (ines8 We":"ased +rograms offer smokers immediate feed"ack to 'e(+ t'em )uit. Man1
of t'e +rograms inc(ude (inks to )uitting resources8 stories from former smokers and cancer
+atients8 (i-e ad-ice from counse(ors8 and message "oards. We":"ased +rograms 'a-e "een
s'own to 'e(+ im+ro-e )uit rates.
I1.or!$n! 7/!!n) s!e.s
?- C&oosn) $ 7/! D$!e
?ac' smoker w'o 'as decided to +ursue a )uit attem+t s'ou(d "e asked to c'oose a )uit date. Idea((1 t'is
date s'ou(d "e wit'in one to two weeks of 'is consu(tation wit' t'e 'ea(t' +rofessiona(. !'is date cou(d
"e a Jirt' %a18 Wedding nni-ersar18 ?id %a18 or *
st
5amadan. (( users s'ou(d "e ad-ised not to smoke
e-en a sing(e cigarette on t'e )uit date. Jetween t'e initia( consu(tation and )uit date8 t'e smoker s'ou(d
tr1 to cut down t'e num"er of cigarettes smoked +er da1. 0mokers often get an urge to (ig't u+ M>ust one
cigaretteN after t'e1 'a-e gi-en u+ smoking. 0mokers must "e strong(1 ad-ised t'at often t'is Minnocent
cigaretteN can immediate(1 (ead to taking u+ smoking again. ?-en one +uff of cigarette wi(( increase t'e
urge to smoke and increase t'e risk of fai(ure in t'eir )uit attem+t.
2- Te%%n) "rends $nd "$1%y
!e((ing friends and fami(1 a"out t'e +(an to )uit rea((1 'e(+s as in t'is wa1 t'e +atient is not
a(one and 'eIs'e gets com+anions in t'e war against to"acco.
@- C&$n)n) ro/!ne $nd re1o2n) re1nders
House'o(d reminders suc' as as' tra1s etc. s'ou(d "e remo-ed and t'e dai(1 routine s'ou(d "e
c'anged. It is of great 'e(+ and re(ief as in t'is wa1 one gets awa1 from t'is e-i( easi(18 as it is
said8 MOut of sig't8 out of mindTN
A- Fo%%o= U. 9s!
!'e +atient must "e seen again "1 t'e 'ea(t' +rofessiona( wit'in se-en to ten da1s of 'is )uit date. !'is is
t'e time w'en smokers are 'a-ing ma3imum nicotine wit'drawa( s1m+toms and t'e +'1sician ma1 "e
a"(e to 'e(+ in reso(-ing some of t'eir concerns.
26
(#O<S PACKAGE FOR CONTROLLING
TOBACCO EPIDEMIC
*eversing this entirely preventable epidemic must now rank as a top
priority for public health and for political leaders in every country of
the world.
(Dr Margaret Chan, WHO Director-General, 2008$
!'e WHO/s MPO(ER .o%,y .$,+$)e can re-erse t'e to"acco e+idemic and +re-ent mi((ions of
to"acco:re(ated deat's.
Monitor to"acco use and +re-ention +o(icies
o %ata from monitoring8 "ot' nationa( and internationa(8 is necessar1 to ensure t'e success
of t'e fi-e ot'er +o(ic1 inter-entions in t'e MPOW?5 +ackage. =ood monitoring
s1stems must track se-era( indicators8 inc(uding
+re-a(ence of to"acco use
im+act of +o(ic1 inter-entions
to"acco industr1 marketing8 +romotion and (o""1ing
Protect +eo+(e from to"acco smoke
o !'ere is no safe (e-e( of e3+osure to second:'and smoke. 0econd:'and smoke e3+osure
increases t'e risk of coronar1 'eart disease "1 25G309 and t'e risk of (ung cancer in
non:smokers "1 20G309 62$7. On t'e ot'er 'and8 smoke:free en-ironments 'e(+ smokers
w'o want to )uit. For e3am+(e8 smoke:free +o(icies in work+(aces in se-era(
industria(i<ed nations 'a-e reduced tota( to"acco consum+tion among workers "1 an
a-erage of 2;9 62;7.
Offer 'e(+ to )uit to"acco use
o mong smokers w'o are aware of t'e dangers of to"acco8 t'ree out of four want to )uit
6307. Howe-er8 (ike +eo+(e de+endent on an1 addicti-e drug8 it is difficu(t for most
to"acco users to )uit on t'eir own and t'e1 "enefit from 'e(+ and su++ort to o-ercome
t'eir de+endence. It is t'e +rimar1 res+onsi"i(it1 of t'e countries/ 'ea(t':care s1stems to
treat to"acco de+endence. !reatment inc(udes -arious met'ods8 from sim+(e medica(
ad-ice to +'armacot'era+1. !reatment s'ou(d "e ada+ted to (oca( conditions and cu(tures8
and tai(ored to indi-idua( +references and needs.
(arn a"out t'e dangers of to"acco
o !o"acco use is usua((1 seen as mere(1 a "ad 'a"it "ut +eo+(e do not rea((1 know t'e
'ea(t' risks associated wit' its use. Peo+(e genera((1 "e(ie-e t'e1 can reduce or sto+
to"acco use "efore 'ea(t' +ro"(ems occur. Howe-er8 t'e rea(it1 is t'at most to"acco users
wi(( ne-er "e a"(e to )uit8 and u+ to 'a(f wi(( die from to"acco:re(ated i((nesses.
!'erefore8 it is e3treme(1 im+ortant t'at we warn t'e genera( +u"(ic8 es+ecia((1 t'e
ado(escents and 1oung adu(ts8 a"out t'e dangers of to"acco. We need to make t'em
2%
rea(i<e t'at to"acco is e3treme(1 addicti-e and dangerous to t'eir 'ea(t'. (( t'is can "e
ac'ie-ed t'roug' action "1 go-ernments and ci-i( societ1.
Enforce "ans on to"acco ad-ertising8 +romotion and s+onsors'i+
o Marketing "ans are 'ig'(1 effecti-e in reducing to"acco use. In t'e .nited 0tates8
nationa(:(e-e( studies "efore and after ad-ertising "ans found a dec(ine in to"acco
consum+tion of u+ to *49 63*:357. .nfortunate(18 to"acco is fa(se(1 associated wit'
desira"(e )ua(ities suc' as 1out'8 energ18 g(amour and se3 a++ea( t'roug' marketing.
(so8 t'e to"acco industr1 'as strong inf(uence o-er t'e s+orting and entertainment
"usinesses -ia t'e media. !'erefore8 t'e to"acco industr1 strong(1 o++oses marketing
"ansC and t'e to"acco industr1 (o""ies 'ea-i(1 against e-en t'e narrowest restrictions.
Raise ta3es on to"acco
o Increasing t'e +rice of to"acco t'roug' 'ig'er ta3es is t'e sing(e most effecti-e wa1 to
decrease consum+tion and encourage to"acco users to )uit 6347. It 'as "een demonstrated
in a stud1 t'at a 209 increase in t'e +rice of to"acco cou(d +re-ent u+ to a )uarter of a((
smoking:re(ated deat's wor(dwide 6327. Hence t'e W.H.O. strong(1 urges its mem"er
countries to increase t'e ta3es on a(( to"acco:re(ated +roducts.
28
P#ARMACOT#ERAPB OF TOBACCO
CESSATION
Ten years ago all we had to offer was going cold turkey or
nicotine gum. The good news for smokers is that people now
have a choice. There+s never been a better time to ,uit.
(Michel C( Fiore, Chair#er&on 1u)co""ittee on Ce&&ation, 21
De#art"ent o Health an! Hu"an 1er+ice&( The To)acco 4tla&
2005$
-irst!line medications
First:(ine medications are t'ose t'at 'a-e "een found to "e safe and effecti-e for to"acco de+endence
treatment e3ce+t in t'e +resence of contraindications or wit' s+ecific +o+u(ations for w'ic' t'ere is
insufficient e-idence of effecti-eness 6i.e. +regnant women8 smoke(ess to"acco users8 (ig't smokers8 and
ado(escents7. !'ese first:(ine medications 'a-e an esta"(is'ed em+irica( record of effecti-eness8 and
c(inicians s'ou(d consider t'ese agents first w'en c'oosing a medication.
!'ere are now t'ree first:(ine medica( o+tions a-ai(a"(e to assist smokers to )uit smoking 63$8 3;7F
@icotine re+(acement t'era+1
Ju+ro+ion
Harenic(ine
2&
30
*. N,o!ne Re.%$,e1en! T&er$.y
$4 N,o!ne G/1
%osage
@icotine gum is a-ai(a"(e in 2 mg and 4 mg 6+er +iece7 doses. !'e 2 mg gum is recommended for +atients
smoking (ess t'an 25 cigarettes +er da18 w'i(e t'e 4 mg gum "eing used for +atients smoking more t'an
25 cigarettes +er da1. =enera((18 t'e gum s'ou(d "e used for u+ to *2 weeks8 wit' no more t'an 24
+iecesIda1. %osage and duration of t'era+1 can "e tai(ored to fit t'e needs of eac' indi-idua( +atient.
%uring t'e first few weeks it is recommended t'at one c'ewing gum "e used e-er1 'our.
Prescri"ing Instructions
*. ,'ewing tec'ni)ue. =um s'ou(d "e c'ewed s(ow(1 unti( a +e++er1 or mint taste emerges8 and
t'en +arked "etween c'eek and gum for *0 minutes or unti( t'e taste dissi+ates to faci(itate
nicotine a"sor+tion t'roug' t'e ora( mucosa.
2. -oid eating and drinking an1t'ing e3ce+t water for *5 minutes "efore and during c'ewing as
acidic "e-erages interfere wit' t'e "ucca( a"sor+tion of nicotine.
3. ,'ew t'e gum on a fi3ed sc'edu(e 6at (east one +iece e-er1 *:2 'ours during waking 'ours7 for at
(east *:3 mont's.
-ai(a"i(it1
@icotine ,'ewing =um 6@ukik 2 mg7
Precautions
Pregnanc1.
#actating women.
,ardio-ascu(ar diseases.
0ide ?ffects
Mout' soreness
Hiccu+s
%1s+e+sia
Saw ac'e. =enera((1 mi(d and transient8 and can often "e a((e-iated "1 correcting t'e +atient/s
c'ewing tec'ni)ue.
b4 N,o!ne P$!,&
%osage
!reatment of $ weeks or (ess 'as "een s'own to "e as efficacious as (onger treatment +eriods. *4 and 24:
'our +atc'es are of com+ara"(e efficac1. ,(inicians s'ou(d indi-idua(i<e treatment "ased on s+ecific
+atient c'aracteristics suc' as +re-ious e3+erience wit' t'e +atc'8 amount smoked8 degree of
addicti-eness8 etc. ,onsider starting treatment on a (ower +atc' dose in +atients smoking *0 or fewer
cigarettes +er da1.
31
Prescri"ing instructions
*. t t'e start of eac' da18 t'e +atient s'ou(d +(ace a new +atc' on a re(ati-e(1 'air(ess (ocation8
t1+ica((1 "etween t'e neck and waist.
2. @o restrictions on acti-it1 w'i(e using t'e +atc'.
3. Patc'es s'ou(d "e a++(ied as soon as t'e +atient wakes u+ on t'eir )uit da1.
4. In +atients w'o e3+erience s(ee+ disru+tion8 ad-ise t'e +atient to remo-e t'e 24:'our +atc' +rior to
"edtime or use t'e *4:'our +atc'.
-ai(a"i(it1
,urrent(1 not free(1 a-ai(a"(e in t'e countr1
5ecommended %osages
*5 mg for $ weeks8
!'en *0 mg for 2 weeks
nd fina((1 5 mg for 2 weeks
Precautions
Pregnanc1.
#actating women.
,ardio-ascu(ar diseases.
0ide effects
#oca( skin reaction. .sua((1 mi(d and se(f:(imiting8 "ut ma1 worsen o-er t'e course of t'era+1.
#oca( treatment wit' '1drocortisone cream 6*97 or triamcino(one cream 60.597 and rotating
+atc' sites ma1 reduce suc' (oca( reactions.
Insomnia.
2- B/.ro.on 3Cy%eDD E; 1)' Cyb$n ?;01)4
Origina((1 de-e(o+ed as an antide+ressant8 "u+ro+ion is a non:nicotine ora( t'era+1 w'ic' reduces t'e
urge to smoke and reduces s1m+toms from nicotine wit'drawa(.
%osage
It is recommended t'at +atients "egin wit' a dose of *50 mg E% for 3 da1s8 t'en increase to *50 mg J%
for 2:*2 weeks. Ju+ro+ion 05 treatment is started *:2 weeks "efore t'e +atient )uits smoking. For
maintenance t'era+18 consider "u+ro+ion 05 *50 mg J% for u+ to 4 mont's.
0ome +atients wi(( (ose t'eir desire to smoke +rior to t'eir )uit date8 or wi(( s+ontaneous(1 reduce
t'e amount t'e1 smoke.
32
If insomnia is marked8 taking t'e PM dose ear(ier 6in t'e afternoon8 at (east $ 'ours after t'e first
dose7 ma1 +ro-ide some re(ief.
-ai(a"i(it1
-ai(a"(e as B1(e33 in Pakistan 625mg ta"(et78 B1"an 6*50 mg ta"(etsC current(1 not a-ai(a"(e in Pakistan7
Precautions
Pregnanc1
#actating women
,ardio-ascu(ar diseases. Infre)uent re+orts of '1+ertension.
0ide effects
Insomnia
%r1 mout'
,ontraindications
Histor1 of a sei<ure
Histor1 of an eating disorder
Patients taking an1 MO in'i"itor
.sing anot'er form of "u+ro+ion i.e. We(("utrin or We(("utrin 05
@- 9$ren,%ne 3C&$n!D 0-; 1) $nd ? 1) T$b%e!s4
Mec'anism of ction
It targets t'e nicotinic acet1(c'o(ine 6,'7 rece+tor in t'e reward centres in t'e "rain8 w'ere it acts as a
+artia( agonist to a((e-iate s1m+toms of cra-ing and wit'drawa(.
%osage
!'e recommended dose of -arenic(ine is * mg twice dai(1 fo((owing a * week titration as fo((owsF
%a1s *:3F 0.5 mg O.%.
%a1s 4:2F 0.5 mg J.%.
%a1 $ G ?nd of treatmentF * mg J.%.
!'e +atient s'ou(d set a date to sto+ smoking and Harenic(ine dosing s'ou(d start * week "efore t'is date.
Patients s'ou(d "e treated for *2 weeks. Once t'e +atient 'as successfu((1 sto++ed smoking at t'e end of
*2 weeks8 an additiona( course of *2 weeks treatment wit' Harenic(ine * mg J.%. is a(so recommended.
-ai(a"i(it1
33
Fi(m coated ta"(ets a-ai(a"(e in 0.5 and * mg strengt's as Harenic(ine start rate.
Precautions
Anown '1+ersensiti-it1 to Harenic(ine
Pregnanc1
#actation
0ide effects
@ausea
Headac'e
Insomnia
"norma( dreams
Second!line medications
0econd:(ine medications are a(so efficacious for treating to"acco de+endence "ut t'eir ro(e is (imited
main(1 "ecause t'e1 ma1 'a-e more +otentia( side effects t'an t'e *
st
(ine medications. !'ese areF
*. ,(onidine
2. @ortri+t1(ine
?- C%ondne
%osage
%ose -aries from 0.*5:0.25 mgIda1 PO to 0.*0:0.20 mgIda1 transderma( 6!!07. !1+ica((18 t'e initia( dose
is 0.*0 mg J% PO or 0.*0 mgIda1 !!08 increasing "1 0.*0 mgIda1 +er week if needed. %uration of
t'era+1 ma1 a(so -ar1 from 3:*0 weeks.
0ide effects
%r1 mout'8 drowsiness8 di<<iness8 sedation and consti+ation. J(ood +ressure s'ou(d "e monitored w'i(e
using c(onidine8 "ecause of its anti'1+ertensi-e effects.
2- Nor!r.!y%ne
!'e dose of nortri+t1(ine used for smoking cessation is a++ro3imate(1 25 mg +er da1 for *2 weeks.
Howe-er8 its a++(ication 'as "een (imited "ecause of its +otentia( for serious side effects. !'ese inc(ude
dr1 mout'8 consti+ation8 nausea8 sedation and 'eadac'es8 and a risk of arr'1t'mia in +atients wit'
cardio-ascu(ar disease. It can "e dangerous in case of an o-erdose.
34
Possible future options
!'ere are a num"er of to"acco cessation t'era+ies and nicotine -accines in de-e(o+ment 640:427. !'e
se(ecti-e t1+e * canna"inoid rece+tor antagonist rimona"ant 6437 and t'e nicotine rece+tor +artia( agonist
c1stine 6447 'a-e demonstrated some efficac1 in studies8 "ut as 1et t'ere is insufficient e-idence for t'eir
use in to"acco cessation. Furt'er data and researc' are needed "efore an1 of t'ese met'ods of treatment
for to"acco de+endenc1 can "e recommended.
35
'n the %&
th
century the tobacco epidemic killed one hundred
million people worldwide. )uring the %(
st
century it could kill
one billion.
/0"# E1P#0E* *eport %&&23
A..endD ?
0ummar1 of effecti-eness data for smoking cessation inter-entions 6a"stinence at (east si3 mont's7 wit'
information from a(( t'e (atest ,oc'rane 5e-iews
In!er2en!on3so/r,e4 7/!
r$!e
3F4
,o1.$r$!or Odd r$!o
39;F ,on"den,e
n!er2$%4
0e(f:'e(+ inter-entions
$
@o inter-ention *.246*.02:*.457
Indi-idua( "e'a-ioura( counse((ing
b
Minima( "e'a-ioura(
inter-ention
*.546*.32:*.$47
P'1sician
ad-ice
,
Jrief ad-ice @o ad-ice *.246*.4$:2.057
Intensi-e ad-ice Minima( ad-ice *.446*.24:*.427
=rou+ "e'a-iour t'era+1
d
@o inter-ention 2.*26*.32:3.457
0e(f:'e(+ +rogramme 2.046*.40:2.407
@icotine re+(acement t'era+1
6@5!7
e
P(ace"o or non:@5! *.5$6*.50:*.447
!e(e+'one counse((ing
"
Wit'out te(e+'one
counse((ing
*.4*6*.22:*.527
#ess intensi-e counse((ing *.336*.2*:*.427
Euit and Win contests
)
$:209 Jase(ine communit1 rate
Ju+ro+ion
&
P(ace"o *.;46*.22 to 2.*;7
Harenic(ine
P(ace"o 2.33 6*.;5 to 2.$07

$. #ancaster !8 0tead #F. 0e(f:'e(+ inter-entions for smoking cessation. ,oc'rane %ata"ase of 01stematic
5e-iews 20058 Issue 3. rt. @o.F ,%00***$. %OIF *0.*002I*445*$5$.,%00***$.+u"2.
b. #ancaster !8 0tead #F. Indi-idua( "e'a-iora( counse(ing for smoking cessation. ,oc'rane %ata"ase of
01stematic 5e-iews 20058 Issue 2. rt. @o.F ,%00*2;2. %OIF *0.*002I*445*$5$.,%00*2;2.+u"2.
36
,. #ancaster !8 0tead #F. P'1sician ad-ice for smoking cessation. ,oc'rane %ata"ase of 01stematic
5e-iews 20048 Issue 4. rt. @o.F,%000*45. %OIF *0.*002I*445*$5$.,%000*45.+u"2.
d. 0tead #F8 #ancaster !. =rou+ "e'a-iour t'era+1 +rogrammes for smoking cessation. ,oc'rane
%ata"ase of 01stematic 5e-iews 20058 Issue 2. rt. @o.F ,%00*002. %OIF
*0.*002I*445*$5$.,%00*002.+u"2.
e. 0tead #F8 Perera 58 Ju((en,8Mant %8 #ancaster !.@icotine re+(acement t'era+1 for smoking cessation.
,oc'rane %ata"ase of 01stematic 5e-iews 200$8 Issue *. rt. @o.F ,%000*44. %OIF
*0.*002I*445*$5$.,%000*44.+u"3.
". 0tead #F8 Perera 58 #ancaster !. !e(e+'one counse((ing for smoking cessation. ,oc'rane %ata"ase of
01stematic 5e-iews 20048 Issue 3.rt. @o.F ,%002$50. %OIF *0.*002I*445*$5$.,%002$50.+u"2.
).He1 A8 Perera 5. Euit and Win contests for smoking cessation. ,oc'rane %ata"ase of 01stematic
5e-iews 20058 Issue 2. rt. @o.F,%004;$4. %OIF *0.*002I*445*$5$.,%004;$4.+u"2.
&. Hug'es S58 0tead #F8 #ancaster !. ntide+ressants for smoking cessation. ,oc'rane %ata"ase of
01stematic 5e-iews 20028 Issue *. rt. @o.F ,%00003*. %OIF *0.*002I*445*$5$.,%00003*.+u"3.
.,a'i(( A8 0tead #F8 #ancaster !. @icotine rece+tor +artia( agonists for smoking cessation. ,oc'rane
%ata"ase of 01stematic 5e-iews 200$8 Issue 3. rt. @o.F ,%004*03. %OIF
*0.*002I*445*$5$.,%004*03.+u"3
3%
A..endD 2
#O( TO ASSESS TOBACCO DEPENDENCE
!'e first ste+ in treating to"acco use and de+endence is to identif1 to"acco users. (( +atients s'ou(d "e
asked if t'e1 use to"acco and s'ou(d 'a-e t'eir to"acco:use status documented on a regu(ar "asis.
!'e assessments are to (ook forF
*. #e-e( of addiction 6using Fagerstrom Euestionnaires U num"er of cigarettes smoked7
2. 5eadiness for )uitting
MODIFIED FAGERSTRGM TEST FOR NICOTINE DEPENDENCE 6457
?- #o= soon $"!er yo/ =$+e /. do yo/ s1o+e yo/r "rs! ,)$re!!e:
a. Wit'in 5 minutes 63 +oints7
". 5 to 30 minutes 62 +oints7
c. 3* to 40 minutes 6* +oint7
d. fter 40 minutes 60 +oints7
2- Do yo/ "nd ! d"",/%! no! !o s1o+e n .%$,es =&ere yo/ s&o/%dn<!' s/,& $s n ,&/r,& or s,&oo%' n $
1o2e' $! !&e %br$ry' on $ b/s' n ,o/r! or n $ &os.!$%:
a. Des 6* +oint7
". @o 60 +oints7
@- (&,& ,)$re!!e =o/%d yo/ 1os! &$!e !o )2e /.H =&,& ,)$re!!e do yo/ !re$s/re !&e 1os!:
a. !'e first one in t'e morning 6* +oint7
". n1 ot'er one 60 +oints7
A- #o= 1$ny ,)$re!!es do yo/ s1o+e e$,& d$y:
a. *0 or fewer 60 +oints7
38
". ** to 20 6* +oint7
c. 2* to 30 62 +oints7
d. 3* or more 63 +oints7
;- Do yo/ s1o+e 1ore d/rn) !&e "rs! "e= &o/rs $"!er =$+n) /. !&$n d/rn) !&e res! o" !&e d$y:
a. Des 6* +oint7
". @o 60 +oints7
I- Do yo/ s!%% s1o+e " yo/ $re so s,+ !&$! yo/ $re n bed 1os! o" !&e d$y or " yo/ &$2e $ ,o%d or !&e
"%/ $nd &$2e !ro/b%e bre$!&n):
a. Des 6* +oint7
". @o 60 +oints7
S,orn):
E !o ?0 .on!s J &)&%y de.enden!H
A !o I .on!s J 1oder$!e%y de.enden!H
%ess !&$n A .on!s J 1n1$%%y de.enden!
3&
A..endD @
SMOKERS< FRE7UENTLB ASKED 7UESTIONS
AND T#EIR ANS(ERS
Fo((owing are some of t'e common(1 asked )uestions "1 smokers w'en t'e1 consu(t a 'ea(t' +rofessiona(
and t'eir +ossi"(e answer. ?-er1 indi-idua( is different and answers ma1 'a-e to "e modified according to
t'e s+ecific situation. W'at message 1ou gi-e to a 1oung +erson ma1 not a++ea( to a midd(e aged +erson.
7?- I $1 I0 ye$rs o%d- I s!$r!ed s1o+n) A0 ye$rs $)o- D$1$)e &$s $%re$dy been done-
Isn<! ! !oo %$!e !o s!o. no=: (&$! =o/%d I )$n by )2n) /. s1o+n) $! !&s $)e:
ns. ItVs ne-er too (ate to gi-e u+ smoking. J1 sto++ing smoking8 furt'er damage to our (ungs8
'eart and ot'er organs wou(d sto+. 5esearc' on res+irator1 functions 'as s'own t'at "1
sto++ing smoking +atient is a"(e to a-oid furt'er deterioration in (ung functions. !'is
(ung function sa-ed mig't in t'e end determine w'et'er a +atient s+ends 'is remaining
(ife in "ed gas+ing for "reat' or wa(king and doing a(( routine +'1sica( work. Eua(it1 of
(ife of an e3 smoker is far su+erior com+ared to one w'o continues 'is smoking 'a"it.
72- I &$2e been s1o+n) "or o2er 20 ye$rs- S&o/%d I ,/! do=n on 1y ,)$re!!es "rs! or
s!o. ! $%!o)e!&er:
ns. 5esearc' 'as s'own t'at t'ose w'o set a firm )uit date and sto+ sudden(18 'a-e a "etter
c'ance of )uitting8 com+ared to t'ose w'o attem+t a gradua( reduction. Howe-er8
reducing t'e num"er of cigarettes in t'e week "efore t'e )uit date is 'e(+fu(.
7@- I $1 $dd,!ed !o !&e n,o!ne .resen! n !&e ,)$re!!es $nd yo/ $re .res,rbn) 1e
n,o!ne ,&e=n) )/1 "or >/!!n) s1o+n)- Isn<! !&ere $ rs+ !&$! I =%% be &oo+ed
on !o n,o!ne ,&e=n) )/1:
ns. @icotine taken t'roug' c'ewing gum on(1 +ro-ides *I3 to *I2 of nicotine de(i-ered "1
cigarettes. It 'e(+s in reducing t'e M,5HI@=N & "reaking t'e "ad 'a"it. ,'ances of
getting 'ooked to nicotine c'ewing gum itse(f are (ess t'an 59. W'en 1ou take nicotine
in gum form8 1ou a-oid t'e ot'er 4200 to3ins +resent in cigarettes. @icotine itse(f does
not cause #ung ,ancer or Heart ttack.
7A- #o= 1$ny ,&e=n) )/1s s&o/%d I /se e2ery d$y:
ns. 0omeone w'o smokes "etween *0:20 cigarettesIda1 needs to use * 62mg7 c'ewing gum
e-er1 'our for a"out *0 to *5 'ours 6during awake 'ours7. Most fai(ures occur "ecause
40
+eo+(e use (ess c'ewing gum t'an t'e1 need. One can a(so use additiona( gum at an1 time
w'en t'ere is an urge. !'ose w'o smoke more t'en 20 cigarettes s'ou(d use a 4 mg
c'ewing gum.
7;- #o= ,$n I /se !&e ,&e=n) )/1 $nd "or &o= %on):
ns. =enera((1 c'ewing gum is re)uired for a +eriod of 2 to 3 mont's. Most +eo+(e tend to
reduce its use as time +asses 6cra-ing for smoking get (ess after t'e initia( 2 weeks7.
O,'ew and +arkO met'od is t'e "est. ,'ewing gum s'ou(d sta1 in t'e mout' for 30
minutes or so.
7I- I don<! %+e !&e b$d !$s!e o" ,&e=n) )/1K I!<s 2ery &$rd !o ,&e=K
ns. 5emem"er it is a medicineC not a sweet or =u(a" Samun. For e3am+(e8 in ma(aria one
takes Euinine w'ic' is -er1 "itter in taste "ut it is im+ortant to take it in order to get
cured from Ma(aria. Most +eo+(e do not (ike t'e taste of t'eir first cigarette "ut after few
da1s t'e1 "egin to en>o1 smoking. 0imi(ar(1 it takes few da1s "efore one starts fee(ing
t'e "enefit of nicotine c'ewing gum use. 0ide effects are Hiccoug'8 Saw ac'e and
Indigestion.
7E- Do $%% s1o+ers need NRT' Cy%eDD 3B/.ro.on4 or 9$ren,%ne $s $ s1o+n) ,ess$!on
$d:
ns. If a +erson smokes (ess t'an *0 cigarettesIda1 and 'as 'ad +re-ious successfu( (ong term
)uit attem+ts wit'out an1 +ro"(ems t'en @5! or ot'er medicines ma1 not "e necessar1.
Jut if +atient 'as tried and fai(ed +re-ious Mse(f attem+tsN of )uitting smoking t'en 'e or
s'e s'ou(d "e ad-ised to use some +'armacot'era+1.
7L- I &$2e !red N,o!ne C&e=n) )/1 be"oreH ! does no! =or+ "or 1eM
ns. @icotine c'ewing gum does not gi-e t'e same M+(easureN as cigarettes. It on(1 +ro-ides
*I3 to *I2 of nicotine t'at t'e cigarette was +ro-iding. It wi(( certain(1 decrease t'e
Mcra-ingN "ut wi(( not gi-e t'e same re(ief as cigarettes. @icotine from ,'ewing gum is
de(i-ered s(ow(1 t'an from in'a(ed smoke. Most +eo+(e w'o fai( do not use ade)uate
amounts of c'ewing gum or are not moti-ated enoug' to get rid of t'is addiction.
79- Is N,o!ne ,&e=n) )/1 $s e""e,!2e $s N,o!ne .$!,&es:
ns. (( @5! 6+atc' or c'ewing gum7 are e)ua((1 effecti-e8 one can com"ine t'e two +roducts
in 'ea-i(1 addicted smokers "ut t'ere is no added "enefit in contro((ed tria(s. !'roug'
skin +atc' t'ere is sustained de(i-er1 of nicotine com+ared to c'ewing gum.
7?0- I &$2e de2e%o.ed 1o/!& /%,er e2er sn,e I s!$r!ed /sn) ,&e=n) )/1M
ns. Mout' u(cers are t'e s1m+toms of nicotine wit'drawa(. It usua((1 sett(es down in a few
da1s. It/s not "ecause of using nicotine c'ewing gum.
41
7??- I &$2e &e$rd !&$! by >/!!n) s1o+n) I =o/%d )$n =e)&!' b/! I =$n! !o %oo+
s1$r!:
ns. Des itVs true t'at one gains a"out 4 kgs of weig't wit'in a 1ear of )uitting smoking.
@icotine c'ewing gum wou(d de(a1 t'e weig't gain. 0(ig't weig't gain 'as far (ess risks
com+ared to t'e serious 'a<ards associated wit' MsmokingN. !'ere is no need to worr1
too muc' a"out weig't gain MEuitting smokingN & Mcontro((ing weig'tN s'ou(d "e
tack(ed at a different time. One cannot c(im" two mountains at an1 one timeT
7?2- C$n I s1o+e one or !=o ,)$re!!es $"!er !&e >/! d$!e:
ns. @o8 not at a((. @ot e-en one cigarette after t'e )uit date. If 1ou take e-en one cigarette
1ou wi(( go "ack to t'e same 'a"it. M%o not feed a d1ing monster in 1our "rainNT
7?@- S1o+n) &e%.s 1e !o re%$D n 1y 2ery &e,!, $nd !ense %"e- (&ene2er I !ry !o >/!
s1o+n) I be,o1e $n)ry $nd s!$r! ")&!n) =!& 1y ,o%%e$)/es-
ns. nger & rest(essness are nicotine wit'drawa( s1m+toms. !'ese s1m+toms (ast on(1 for a
few weeks. It can "e contro((ed "1 @5! or wit' ta"(et BDJ@. W'at 1ou ca((
re(a3ation is actua((1 a re(ief from t'e Mwit'drawa(N s1m+toms of nicotine addiction.
7?A- My %"e s 2ery s!ress"/%- S1o+n) &e%.s 1e n ,o.n) =!& s!ress-
ns. It is wrong to sa1 t'at smoking decreases stress (e-e(s. 0tudies 'a-e s'own t'at stress
(e-e( at 4 weeks after )uitting smoking is far (ess t'an t'e stress (e-e( during smoking.
0mokers get *0 G *5 e+isodes of stress e-er1 da1 w'ic' is re(ie-ed "1 smoking. In t'e
first week after )uitting smoking8 smokers are more an3ious "ut soon an3iet1 (e-e( goes
down. 6=i-e e3am+(e of Heroin addiction7.
7?;- #o= do I /se B/.ro.on:
ns. Dou s'ou(d start one week +rior to )uit date. Initia((1 take *50 mg dai(18 t'en on t'e da1
of )uitting increase B1"an to *50 mg I twiceI da1. ,ontinue B1"an for a"out 2 to 3
mont's.
7?I- Is !&ere $ny ,on!r$ nd/,!on !o /se o" B/.ro.on :
ns. If some"od1 'as HIO e+i(e+s1 or sei<ures t'en B1"an s'ou(d not "e used.
7?E- (&$! do I do " I )e! rress!b%e desre !o s1o+e:
ns. %e(a18 ?sca+e8 %istractC 5emem"er t'e MurgeN to smoke (asts for 4 minutes on(1.
7?L- My /n,%e s1o+ed $%% &s %"e b/! &e s s!%% $%2e $! $)e L0- I" s1o+n) s so b$d !&en
=&y &e s s!%% $%2e:
ns. ItVs true t'at some +eo+(e are more -u(nera"(e to t'e effects of to"acco use t'en ot'ers.
=enetic make u+ of t'e indi-idua( does +(a1 a ro(e in deciding t'e e3tent of damage
caused "1 to"acco. 5esearc' 'as 'owe-er c(ear(1 s'own t'at 'a(f of a(( regu(ar smokers
42
wi(( die +remature(1 from t'eir smoking 'a"it. On an a-erage8 smokers (oose a"out *0
1ears of t'eir (ife. For some smokers8 1ears (ost "ecause of smoking ma1 "e as man1 as
35 1ears to as (ow as * to 2 1ears .!'e )ua(it1 of (ife of a smoker is a(so muc' inferior
com+ared to t'at of a non:smoker.
7?9- L"e s "/%% o" rs+s n $ny ,$se !&en =&y !&ere s so 1/,& !$%+ $)$ns! s1o+n) !&ese
d$ys: (&$! s !&e &$r1 " so1e one s1o+es:
ns. ItVs true t'at (ife 'as man1 risks. =od 'as +ro-ided us wit' a "rain to t'ink and we s'ou(d
a-oid a(( t'ose actions8 w'ic' tend to 'arm our 'ea(t'. 0moking is toda1 t'e sing(e (argest
+re-enta"(e cause of disease and deat'. cti-e or +assi-e smoking 'as serious 'ea(t'
risks. Euitting smoking is in our 'and. We can +rotect ourse(-es from se-era( diseases
w'ic' are direct(1 caused "1 to"acco a"use.
7 20 (&$! $re !&e sde e""e,!s o" 9$ren,%ne $nd $re !&ere $ny ,on!r$nd,$!on !o !s /se
ns. In genera( Harenic(ine is a safe medicine. Its main side effect is nausea w'ic' usua((1
occur in t'e first week of t'e t'era+1. It/s current(1 not recommended for use during
+regnanc1 and for some one w'o 'as 'istor1 of e+i(e+s1.
43
REFERENCES
*. Wor(d Hea(t' Organi<ationF !'e Wor(d Hea(t' 5e+ort 2003
2. WHO re+ort on t'e g(o"a( to"acco e+idemic 200$8 !'e MPOW?5 +ackage
3. InF !'e !o"acco t(as8 !'ird ?dition 200;8 merican ,ancer 0ociet18 t(anta8 =eorgia .0.
4. Jurgri D8 J'ugri 8 Hasan 0H8 .sman et a(. ,ancer Patterns of Aarac'i di-ision 6*;;$:*;;;7
6 7a% Me! 4&&oc( 2002 Sune 52 64724:4
5. 0tead #F8 Jergson =8 #ancaster !. P'1sician ad-ice for smoking cessation. ,oc'rane %ata"ase of
01stematic 5e-iews 200$8 Issue 2. rt. @o.F ,%000*45. %OIF *0.*002I*445*$5$.
,%000*45.+u"3.
4. Pir1ani 5 M8 5i<-i @. 0moking 'a"its amongst 'ouse +'1sicians working at Sinna' Postgraduate
Medica( ,enter8 Aarac'i8 Pakistan Tro# Doct( 2004 SanC346*7F44:57
2. A'an FM8 Husain 0S8 #aee) 8 wais 8 Hussain 0F8 A'an S. 0moking +re-a(ence8 know(edge
and attitudes among medica( students in Aarac'i8 Pakistan. 8a&t Me!iterr Health 6( 2005 0e+:
@o-C **65:47F;52:$.
$. Int S !u"erc #ung %is. 2002 %ecC**6*27F*344:2*. ,igarette smoking among ado(escent fema(es
in Pakistan. =anatra H8 Aa(ia 08 Ha)ue 08 A'an S.
;. Imam 0B8 @awa< H8 0e+a' DS8 Pa"ane1 H8 I(1as M8 ='affar 0. .se of smoke(ess to"acco
among grou+s of Pakistani medica( students : a cross sectiona( stud1. 9MC 7u)lic Health. 2002
0e+ 3C2F23*.
*0. Wor(d Hea(t' Organi<ation. To)acco3 !ea!l, in an, or" or !i&gui&e. =ene-a8 Wor(d Hea(t'
Organi<ation82004
'tt+FIIwww.w'o.intIto"accoIcommunicationsIe-entsIwntdI2004I!fiW5a++ort.+df
**. Wor(d Hea(t' Organi<ation. Worl! health re#ort 2002. =ene-a8 Wor(d Hea(t' Organi<ation8 2002
'tt+FIIwww.w'o.intIw'rI2002IO-er-iewW?.+df.
*2. =ott(ie" @. Indian cigarettes gain +o+u(arit18 "ut don/t (et t'e f(a-or foo( 1ou. 6ournal o the
/ational Cancer :n&titute, ;5558 ;*62*7F*$04G*$02.
*3. Anow(edge8 attitudes and +ractice of uni-ersit1 students regarding water+i+e smoking in
Pakistan. . Sawaid8 . M. Bafar8 !:.. 5e'man8 M. 5. @a<ir8 B. . ='afoor8 O. f<a(8 S. .A'an.
:nt 6 Tu)erc <ung Di& *26;7F*022G*0$4
*4. West 58 Mc@ei(( 8 5aw M. 0moke(ess to"acco cessation guide(ines for 'ea(t' +rofessiona(s in
?ng(and. 9r Dent 6( 2004 Ma1 22C*;46*07F4**:$.
*5. ,a(ifornia ?n-ironmenta( Protection genc1. 7ro#o&e! i!entiication o en+iron"ental to)acco
&"o%e a& a toxic air conta"inant3 executi+e &u""ar,. 0acramento8 ,a(ifornia ?n-ironmenta(
Protection genc18 Sune 2005 ft+FIIft+.ar".ca.go-Icar"isIregactIets2004Ia++3e3e.+df
*4. ..0. %e+artment of Hea(t' and Human 0er-ices. The health con&e-uence& o in+oluntar,
ex#o&ure to to)acco &"o%e3 a re#ort o the 1urgeon General. t(anta8 ..0. %e+artment of Hea(t'
and Human 0er-ices8 ,enters for %isease ,ontro( and Pre-ention8 ,oordinating ,enter for Hea(t'
44
Promotion8 @ationa( ,enter for ,'ronic %isease Pre-ention and Hea(t' Promotion8 Office on
0moking and Hea(t'8 2004
'tt+FIIwww.surgeongenera(.go-I(i"rar1Isecond'andsmokeIre+ortIfu((re+ort.+df
*2. Je'an %F8 ?riksen MP8 #in D. 8cono"ic eect& o en+iron"ental to)acco &"o%e. 2005
'tt+FIIwww.soa.orgIfi(esI+dfI?!05e+ortFina(%raft6Fina(92037.+df
*$. Mc='ee 0M et a(. ,ost of to"acco:re(ated diseases8 inc(uding +assi-e smoking8 in Hong Aong.
To)acco Control8 20048 *5627F*25G*30.
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20. Postma %08 0iafakas @M8 eds. Management of ,'ronic O"structi-e Pu(monar1 %isease. 8ur
=e&#ir Mon *;;$C 2.
2*. ..0. %e+artment of Hea(t' and Human 0er-ices. The health con&e-uence& o &"o%ing3 a re#ort
o the 1urgeon General. t(anta8 ..0. %e+artment of Hea(t' and Human 0er-ices8 ,enters for
%isease ,ontro( and Pre-ention8 @ationa( ,enter for ,'ronic %isease Pre-ention and Hea(t'
Promotion8 Office on 0moking and Hea(t'8 2004
'tt+FIIwww.cdc.go-Ito"accoIdataWstatisticsIsgrIsgrW2004Ic'a+ters.'tm
22. !Xnnesen P8 ,arro<<i #8 FagerstrYm AO8 =rat<iou ,8 Simene<:5ui< ,8 @ardini 08 Hiegi =8
#a<<aro ,8 ,am+e(( I8 %ag(i ?8 West 5. 0moking cessation in +atients wit' res+irator1 diseasesF
a 'ig' +riorit18 integra( com+onent of t'era+1. 8ur =e&#ir 6( 2002 Fe"C2;627F3;0:4*2.
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smoking. Che&t 2003C *23F *230G*23;.
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re+(ication and e3tension. 4rch Gen 7&,chiatr, *;;*C 4$F 52G5;.
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Wit'drawa( in ,(inica( tria(s. /icotine To) =e& 2004C 4F 5;;G4*4.
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Che&t Me!( *;;* %ecC*2647F222:35.
2$. 24..0. %e+artment of Hea(t' and Human 0er-ices. The health con&e-uence& o in+oluntar,
ex#o&ure to to)acco &"o%e3 a re#ort o the 1urgeon General. t(anta8 ..0. %e+artment of Hea(t'
and Human 0er-ices8 ,enters for %isease ,ontro( and Pre-ention8 ,oordinating ,enter for Hea(t'
Promotion8 @ationa( ,enter for ,'ronic %isease Pre-ention and Hea(t' Promotion8 Office on
0moking and Hea(t'8 2004
'tt+FIIwww.surgeongenera(.go-I(i"rar1Isecond'andsmokeIre+ortIfu((re+ort.+df
2;. Fic'ten"erg ,M8 =(ant< 0. ?ffect of smoke:free work+(aces on smoking "e'a-iourF s1stematic
re-iew. 9riti&h Me!ical 6ournal8 20028 325623527F*$$.
30. Sones SM. 1"o%ing ha)it& &ta)le> "o&t 'oul! li%e to -uit. *$ Su(1 2004
6'tt+FIIwww.ga((u+.comI+o((I232;*I0moking:Ha"its:0ta"(e:Most:Wou(d:#ike:Euit.as+38
accessed 4 %ecem"er 20027.
3*. 0mee , et a(. 8ect o to)acco a!+erti&ing on to)acco con&u"#tion3 a !i&cu&&ion !ocu"ent
re+ie'ing the e+i!ence. #ondon8 ?conomic and O+erationa( 5esearc' %i-ision8 %e+artment of
Hea(t'8 *;;2.
32. Countr, #roile&. Fift' WHO seminar for a !o"acco:Free ?uro+e8 Wor(d Hea(t' Organi<ation
5egiona( Office for ?uro+e8 Warsaw8 24G2$ Octo"er *;;5.
45
33. S'a P8 ,'a(ou+ka FS. Cur)ing the e#i!e"ic3 go+ern"ent& an! the econo"ic& o to)acco control.
Was'ington8 %,8Wor(d Jank8 *;;; 'tt+FIIwww.g(o"a(ink.orgIto"accoIw"Iw"04.s'tm(
34. Pu"(ic 'ea(t' at a g(ance G !o"acco contro(. Wh, i& re!ucing u&e o to)acco a #riorit,?
Was'ington8 %,8Wor(d Jank8 2003
'tt+FIIsiteresources.wor(d"ank.orgII@!PH=I5esourcesI=!o"ac,ontro(?ng-44:03.+df
35. WHO !o"acco Free Initiati-e. 9uil!ing )loc%& or to)acco control3 a han!)oo%( =ene-a8 Wor(d
Hea(t'Organi<ation82004
'tt+FIIwww.w'o.intIentit1Ito"accoIresourcesI+u"(icationsIgenera(IH@%JOOA920#owres
920wit'920 Zco-er.+df
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!e+elo#ing countrie&8 2
nd
ed. @ew Dork8 O3ford .ni-ersit1 Press and Was'ington8 %,8Wor(d
Jank8 2004F $4;G$$5 'tt+FIIfi(es.dc+2.orgI+dfI%,PI%,P44.+df
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guide(ine. 5ock-i((e8 M%F ..0. de+artment of 'ea(t' and 'uman ser-ices. Pu"(ic Hea(t' 0er-ice.
Sune 2000.
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cessation +'armacot'era+1F an u+date for 'ea(t' +rofessiona(s. Me("ourneF 5o1a( ustra(ian
,o((ege of =enera( Practitioners8 2002.
3;. Fou(ds S8 0tein"erg MJ8 Wi((iams SM8 Biedonis %M. %e-e(o+ments in +'armacot'era+1 for
to"acco de+endenceF +ast8 +resent and future. Drug 4lcohol =e+ 2004C 25F5;G2*.
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2002C42F54*G44.
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re(ated diseasesL 7<o1 Me! 2005C 2Fe244.
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2004C*44F*553G;.
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internet "ased smoking cessation +rogram. To)acco Control 2004C*5F2G*2.
45. da+ted wit' +ermission from Heat'erton !F8 Ao<(owski #!8 Frecker 5,8 and FagerstrYm AO.
!'e FagerstrYm test for nicotine de+endenceF a re-ision of t'e FagerstrYm !o(erance
Euestionnaire. 9r 6 4!!ict *;;*C $4F***;:22.

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