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Treating Tobacco Use and Dependence: A Clinical Practice Guideline

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... .plays a role in the process of smoking,especially in male adolescent Smoking initiation ... Smoking Cessation Treatment ... of smoking counseling ... – PowerPoint PPT presentation

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Title: Treating Tobacco Use and Dependence: A Clinical Practice Guideline


1
Treating Tobacco Use and DependenceA Clinical
Practice Guideline
  • ??.??.???????? ?????????
  • ???????????????????????????????????????
  • ?????????????????? ?????????????
  • ??????????????????

2
  • ?????
  • ???????????????????????
  • ??????????????????????
  • ????????? smoking program
  • ??????????????
  • ????????

3
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4
????????????
  • ??????????????????? 4 ???????????
    ???????????????? 42 ????
  • ????? ???????????????? ???? 42,000 ??
  • ????? 115 ??
  • ????????? 5 ??
  • ??????? ???????????????? ???? 4 ???? ??
  • ????? 11,000 ??
  • ????????? 420 ??
  • ?????????????? 1 ??????? 2 ??????????????
  • ????????????????? 40,000 ????????????

Tobacco or Health A global status report.
WHO,1997
5
??????????????????????????
  • ??????????????????? 4 ???????????
    ???????????????? 42 ????
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6
(No Transcript)
7
90 begin "18"
Pierce JP,et al. J Natl Cancer Inst
1991831008-13.
8
Sexual content of advertisement and the smoking
process in adolescents
  • Raul H Sansores,et al
  • Chest 2002 121(6)2016-22.

9
High percentage of adolescent perceived sexual
content in tobacco advertisement,.plays a role
in the process of smoking,especially in male
adolescent
Chest 2002121(6)2016-22.
10
Smoking initiation at an early age is associated
with greater cigarette consumption,and lower
cumulative probability of quitting
  • Breslau N,Peterson EL. Am J Public Health
    199686214-20.

11
????????????????????????
  • ?? 1995 ??????????????? 23 ?????????????????????
    ????????????
  • ???????????????????????????????? 1
    ???????????????? 25 ??/??
  • ????????????????????? ??????????????
    ???????????????????????

12
?????????????????
  • ????????
  • ?????????
  • ????????????????????

13
???????.????.????????????
  • ????? Stress
  • ??? Learning Theory Pavlov
  • ??? Nicotine

14
??????????????????????
  • 1. ??????????????? ???? genetics,
    neurotransmitter
  • 2. ?????????????????????
  • 3. ????? ??????????

15
????????????????????
16
??????????????? trigger ??? smoking
  • 1. Trigger / avoiding
  • 2. Through / though stopping technique
  • 3. Craving
  • 4. Smoking

17
Tobacco Use
  • Features of chronic disease
  • Minority of tobacco users permanent
    abstinence
  • Majority persist, multi periods of
    relapse remission
  • Relapse is common that reflects the nature of
    dependence, not their own or their patients
    failure

18
Smoking Cessation Treatment
  • Essential treatment skills
  • Standard of good practice
  • Extremely cost-effective relative to other common
    disease prevention's and medical treatments

19
?????????? US Public Health Service
  • 1. Nature of Tobacco dependence
  • 2. Effective treatments exist
  • 3. Role of clinicians and health care systems
  • 4. Brief tobacco dependence treatment is
    effective
  • 5. Correlation between intensity of smoking
    counseling its effectiveness
  • 6. Types of counseling
  • 7. Pharmacothrapies are effective
  • 8. Tobacco dependence treatments are
    cost-effective

20
Assessing Tobacco Use
Pts present to Health Care Setting
Yes
No
Using Tobacco
Yes
No
No
Yes
Willing to Quit
Once ever use
Promote Motivation
Promote Relapse
No intervention
Provide Tx
21
Fagerstrom Test for Nicotine Dependence
  • 1. ????????????????????????
  • 2. ???????????????????????????????????????
  • lt10
  • 11-20
  • 21-30
  • gt31
  • lt 5 min
  • 6-30 min
  • 31-60 min
  • gt60 min

0 1 2 3 3 2 1 0
22
Fagerstrom Test for Nicotine Dependence
  • 3. ?????????????????????????????
  • 4.???????????????????????????????????
  • 5.??????????????????????????????
  • 6.?????????????????????????
  • ???
  • ??????
  • ????????????????
  • ????????
  • ?????
  • ?????????
  • ???
  • ??????

1 0 1 0 1 0 1 0
23
Fagerstrom Test for Nicotine Dependence
  • 10
  • 8-9
  • 6-7
  • 4-5
  • 0-3
  • Very High Nicotine dependence
  • High Nicotine dependence
  • Moderate Nicotine dependence
  • Low to moderate Nicotine dependence
  • Non Nicotine dependence

ColdTurkey
24
Brief Strategies to Help the Patient
  • ??????????????????? 5 As
  • 1. Ask systematically identified
  • 2. Advise clear
  • Strong
  • Personalized
  • 3. Assess willingness
  • 4. Assist aid the patient quitting, use Pharm Tx
  • 5. Arrange schedule follow - up
  • Interventions as brief a 3 min increase
    cessation rates

25
For Patient Unwilling to Quit
  • ??????????????????? 5 Rs
  • 1. Relevance ??????? ??????????????????
  • 2. Risk acute, long-term, environmental
  • 3. Rewards ??????????????????
  • 4. Road blocks ??????? ??????????????
  • 5. Repetition ????? ? ?????????????????????????

26
For Patient recently Quit
  • Minimal Practice Relapse Prevention
  • ???????????
  • ??????? ????????,
    ???????????????? (maintaining)

  • ?????????????? ?????????????????
  • Prescriptive relapse Prevention
  • ???????????? Schedule F/U, identify source of
    support
  • ??????????? Counseling, medication
  • ????? Pharmacological Tx
  • ??????? diet, reassure, Pharmacological Tx
  • ???????? reassure, rewarding activities,
    emphasize
  • beginning to smoke make worse

27
????????? Intensive Smoking Cessation Intervention
  • Component Strategy
  • 1. Assessment ??????????????????

  • ????????????????
    ?????????????????????
  • 2. Program clinicians ???????????????
  • 3. Program intensity Dose-response relationship
  • 4 or more sessions, longest
  • session gt 10 min, total contact time
    gt 30 min

28
????????? Intensive Smoking Cessation Intervention
  • Component Strategy
  • 4. Program format individual, group, telephone
  • F/U assessment
  • 5. Pharmacotherapy ??????????????????????
    ????????
  • ???????
  • 6. Population ?????????????????

29
??????????????
  • 1. ??????????????????????????????????????????
  • ?????? ?????????
  • ??????????? ?????? ?????
  • ???????????
  • 2. ??????????????????????
  • ?????????????????????????????
  • ???????????????
  • ?????????????????????????????

30
??????????????
  • 3. ?????????????????? ?
  • ?????????????
  • ??????????
  • ????????????????????
  • 4. ???????? ?????????????? ????????????

31
????????????????????????????????
  • ??????????????????? ????
  • ???????????????????????????? ?????????????????????
    ???? ??????????? ???????? ??????????????????
  • ????????????? 1 ??? 2 ?????
  • ???????????????????????????????????????

32
??????????
  • First line
  • Non-nicotine OR 2.10 (1.5-3.0)
  • 1. Bupropion SR
  • Nicotine OR 1.71 (1.60-1.83)
  • 1. Nicotine gum
  • 2. Nicotine patch
  • 3. Nicotine spray
  • 4. Nicotine inhaler

33
??????????
  • Second line
  • 1. Nortriptylline
  • 2. Clonidine
  • ??????? anti-nicotine vaccine TA-NIC

34
???????????????????????????
  • 1. Medical C/I
  • 2. Smoking lt 10 / day
  • 3. Pregnancy
  • 4. Breast feeding
  • 5. Adolescent

35
Bupropion HCL SR
  • Blocks neural reuptake of dopamine and/or
    norepinephrine
  • Non-competitive inhibitor
  • Antidepressant ??????? anxiolytic
  • T1/2 8-24 ??.

36
????????
  • ???????? 150 mg ????? 1 ???? 3 ???
    ???????????? 2 ?????
  • ???????? 7-12 ???????, prevent relapse 2-3 ??
  • ???????????????????????? tapper off

37
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38
Bupropion Randomized Trial
abstinent
Plt0.05
39
COPD Study-Point Prevalence Quit Rates








lt0.05
0.07
40
S/E of Bupropion SR
  • 1. Insomnia 35-40
  • 2. N / V
  • 3. Dry mouth
  • 4. ???????

41
Evidence Based of Bupropion Therapy
  • Increased continuous abstinence rate 6,12 months
  • NNT 4-5 case 7-9 weeks
  • Hurt,et al. NEJM 1997, Jorenby et al. NEJM 1999

42
Nicotine Replacement Therapy
  • Nicotine gum
  • - Nicorette/ 2, 4 mg) 8-12 tab/day
  • - ?????????? PU, MI, arrhythmia, esophagitis
  • TM joint dis, Preg/lactation
  • Nicotine patch
  • - Nicotinell TTS 10, 20, 30
  • - ??????????? ?????? ????? ????????????????
  • ???????????????????????????????
  • ????????????????????? 3 ?????

43
?????? Nicotine Gum
  • ?????????? ????????? ?????????????????????????????
    ??????????
  • ??????
  • ?????????????????????????????????????? ???? ????
    ??????? 15 ????
  • ??? 4 mg ??????? 25 ???/???
  • Schedule use q 1-2 hr for 1-3 months may better
    than as need use

44
Evidence Based of NRT Therapy
  • All form of NRT effective insmoking cesstion
  • NRT increased quit rate x 1.5-2
  • The effectiveness of NRT not depend on other
    supports modes
  • A US public Health Service Report, JAMA
    20002833244-54.

45
Multiple pharmacotherapy
  • Combination bupropion SR ??? Nicotine
  • ????????????? ????????????????????????????

46
????????????????????? ??????????
??????? ?????? ?????????
????????????
??????????????????????????
????????? ?? ??????? ?????????????
???????????
47
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    ?????????????????????????
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