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Clinical Practice Guideline in Smoking Cessation 2546
Clinical Practice Guideline in Smoking Cessation 2546

Clinical Practice Guideline in Smoking Cessation

2546

- -

(counseling and behavioral therapies) (pharmacotherapy)

1 3 1,100

15

500

2

2-3

(counseling and behavioral therapies) (pharmacotherapy)

1.

2.

3. /

4.

5.

6.

7.

8.

1

1 1 1 2 4 3 4 : 10 15 5 20

1

1

2

4

3

4

:

10

15

5

20

2

 

6

23

7

8

27

30

9

35

10

 

53

 

1

58

2

Vital Signs

59

3

- 5 A’s

 

60

4

61

5

Pros and Cons

65

6

(5 R’s)

66

7

67

8

68

9

69

10

Fagerstr Öm

70

11

DSM IV

71

12

72

13

73

14

74

15

75

16

76

17

77

18

78

19

79

20

80

21

81

22

82

23

(nicotine withdrawal symptoms)

83

24

84

25

/

90

26

92

98

103

1

1

2003 10

70 1 3 1 6

2544 11

51.3 ( ) 10.6

2542 10

6 25 1.5

22.7 16.4 18.5 10.6

(burden of disease) ( )

2020

( )

25

2020

10

4

1998 4.9

2030

1990

20.6 10.2 ( 20.5)

20

1 3

1 2

2

2546) 3

(73.3 ) (55.3 ) / (51.2 ) 42,000 115 5 3 3,000

2544 2 3 ( 66.8)

(

( 7 ) 10.6 11 4,000 4,000.- 18.5 42 23.5 43,000.-

(1998)

2-3 1.1

2000 2

4

( 1.1)

2025 12

2050

3

1.1

3 1.1 (smoking related mortality) (current course) (prevention effect) ( Projections of smoking-related mortality based on

(smoking related mortality)

(current course)

(prevention effect)

(

Projections of smoking-related mortality based on present trends (current course), compared with projections of effective prevention (prevention effect) and effects of combined prevention and treatement (prevention and treatment effect). (Source : Henningfield and Slade, 1998)

(prevention and treatment effect).

: Henningfield and Slade, 1998)

2.5 1 3

(nicotine replacement therapy NRT) bupropion

1.

2.

3.

(

)

4

2

( 6) ( 7) ( 8) ( 9) ( 10) ( 24) ( - 25)

( 2.1 2.2)

(1) (2)

(3)

(4)

5

2.1 (Ask) (Advise) (Assess) (Assist) (Arrange follow up)
2.1
(Ask)
(Advise)
(Assess)
(Assist)
(Arrange
follow up)

6

2.2

( )
( )
6 2.2 ( ) ( ) Relevance Risks Rewards Roadblocks Repetition 5 R’s 1. 2. -

6 2.2 ( ) ( ) Relevance Risks Rewards Roadblocks Repetition 5 R’s 1. 2. -

( ) Relevance Risks Rewards Roadblocks Repetition 5 R’s 1. 2. - -
(
)
Relevance
Risks
Rewards
Roadblocks
Repetition
5 R’s
1.
2.
-
-
/
- /
3.
( )
-
-
-

7

 

 

1.

Vital Signs

(

= B*)

- 2.3

- “ Vital Signs” ( 2)

(Ask)

- “ - ” ( 3)

(

= A*)

- “5 A’s ( 4)

2.

pros cons (Advise)

(

= A*)

- “ pros and cons” ( 5)

- “5 A’s ( 4)

- “ (5 R’s)” ( 6)

( 30 ) (Assess)

3.

1

- “5 A’s

( 4)

- ( 7)

(

= C*)

- “ ” ( 8)

- “ (5 R’s)” ( 6)

 

2 ( )

- “ ” ( 7)

- ( 10)

- “ ( 8)

 

- “5 A’s ( 4)

8

 

 

3

- “5 A’s ( 4)

- “ ( 9)

 

4

- “5 A’s ( 3)

- “ ( 9)

4. (Assist)

5 1

-

Fagerstr Öm ( 10)

( 3) ( - )

- DSM IV ( 11)

- ( 6)

-

(

= A*)

( 12)

- ( 7)

- ( 3)

-

( 13)

-

( 14)

1.

( 3)

2.

( 4)

9

5. (Arrange follow-up)

(

= A*)

   

-

- “ ( 15)

 

-

-

-

1

* 1 2.3
*
1
2.3
?

?

?
?
?
?

- - “ ( 15)   - - - 1 * 1 2.3 ? ?
- - “ ( 15)   - - - 1 * 1 2.3 ? ?

?

- - “ ( 15)   - - - 1 * 1 2.3 ? ?

- - “ ( 15)   - - - 1 * 1 2.3 ? ?

10

3

( 8)

1.

(Transtheoretical model of change)

6

Transtheoretical model of change

   

 

1. Recent acquisition

-

-

6

2. Precontemplation

6

3. Contemplation

6

4. Preparation

30

-

1

6

5. Action

6. Maintenance

6

-

6

 

( 1-3 Transtheoretical model of change) /

2.

2

11

2.1

( 1 ) ( ) ( ) 2.2 ( Fagerstrom tolerance scale 30 20 ) ( ) ( )

3.

( 3 ) 30 (

10 ) (

= A)

4.

(

= C)

( = B)

(

1)

)

2)

3)

/

12

1)

 

/

1.

-

( 16)

-

( 17)

 

-

( 9)

2.

/

( )

-

( 18)

 

- “ ” ( 19)

-

( 20)

-

( 21)

- “ ” ( 22)

3.

( ) ( 1-3 )

- ( 10)

-

( 7)

- ( 6)

 

- “ ( 23)

13

2)

 

/

1.

- “ ” ( 14)

 

 

2.

 

-

 

-

-

3.

 

-

-

 

-

-

14

3)

 

/

1.

 

 

2.

 

 

3.

 

15

4

:

US Agency

for Health Care Policy and Research

2

1 first-line agent

(nicotine replacement therapy-NRT)

(chewing gum) (patch)

(nicotine sublingual tablet) (lozenge) (oral inhaler) (nasal spray)

bupropion sustained release (SR)

2 second-line agent clonidine nortriptyline

9

/

 

1.

10

2. first-line agent

NRT 2

-

(nicotine chewing gum nicotine polacrilex)

 

(nicotine patch) bupropion SR 2

-

3.

16

/

4. ( 10-15 )

bupropion SR

5. second-line agent

nortriptyline clonidine

6. second-line agent

first-line agent first-line agent second-line agent

7.

bupropion SR

8.

bupropion SR nortriptyline

9.

NRT

10. ( 6 )

bupropion SR

 

11.

NRT NRT bupropion

first-line agent

2

1.

Nicorette ® 2

2 4

2.

Nicotinell TTS ® 4

(24 16 )

17

30 52.5 21 20 35 14 10 17.5 7

(dopamine)

Quomem ® (sustained release) 150

bupropion SR

<25 / 2 ./ / 2-3 ( = A*) ( 7-15 / > 30 /
<25 /
2
./ /
2-3
(
= A*)
(
7-15 /
> 30
/
4-6
)
3
6
30
1
1-2 .
15
3
1
2-4 .
3
1
4-8 .
9
( )
> 25 /
./ /
15 /
4
2-3
(
3
= A*)
(
4-6
6
1
1-2 .
)
20 /
30
3
1
2-4 .
3
1
4-8 .
9

18

20 /

20 10

6-8

3-4

= A*)

(

 

 

12

 

20 /

30 20 10

3-4

4-6 . 30

3-4

3-4

 

 

(

12

)

1 ) 9

(

 

bupropion SR

150

3

 

-

= A*)

(

1

 

   

-

150 2 -

4

1-2

 

 

7-12

2 8 . )

(

9

19

second-line agent (nortriptyline clonidine)

clonidine nortriptyline clonidine A nortriptyline B Clinical Practice Guideline: Treating Tobacco Use and Dependence (Fiore et al., 2000) First-line agent

clonidine

nortriptyline

20

5

bupropion SR 1

(NRT)

(

= B*)

 

1.

q

q

q

q

q

21

2.

3.

4.

5. 3

6.

( )

7. -

3 4 1

bupropion SR ( = C*)

(secondhand smoking)

50 ( ) ( = A*)

22

2

23

6

(nicotine) 9-13 1.8-3.25 20-25

(cotinine)

1980

1980

( )

2 (cerebral cortex) (limbic system) brain reward pathway

ventral tegmental area (VTA) (dopamine) nucleus accumbens (NA) ( 6.1-6.2)

24

6.1 Brain rewarding pathway

24 6.1 Brain rewarding pathway 6.2 nicotine VTA Nicotine A N receptor Dopamine Dopamine vesicle transporter

6.2 nicotine

VTA Nicotine A N receptor Dopamine Dopamine vesicle transporter N Dopamine Dopamine D 1 D
VTA
Nicotine
A
N
receptor
Dopamine
Dopamine vesicle
transporter
N
Dopamine
Dopamine
D 1
D 2
receptor
NAc
Motivation, Mood
(shell region)
VTA Nicotine B N N D 1 D 2 NAc Pleasurable feeling (shell region)
VTA
Nicotine
B
N
N
D 1
D 2
NAc
Pleasurable feeling
(shell region)

A

VTA

dopamine receptor

nucleus accumbens

B

nicotine nicotine nicotinic receptor VTA

6 ( ) brain reward pathway (nicotine receptor) brain reward pathway acetylcholine, serotonin, norepinephrine, glutamate, vasopressin, beta-endorphin, gamma-aminobutyric acid (GABA) nicotine receptor dopamine 6.1

25

6.1

dopamine acetylcholine serotonin norepinephrine glutamate vasopressin

β -endophin γ -aminobutyric acid

dopamine acetylcholine serotonin norepinephrine glutamate vasopressin β -endophin γ -aminobutyric acid

(nicotine withdrawal syndrome) (cigarette craving) brain reward pathway

1. DSM IV (The Diagnostic and Statistical Manual of Mental Disorders 4 th edition)

American Psychiatric Association

(nicotine dependence)

(tolerance)

( )

2. Fagerstr Ö m tolerance test

10)

Fagerstr Ö m Test (

26

(nicotine withdrawal symptoms)

4

3-5

2

DSM IV

2

1. 2-3 2. 4 24

2.1

2.2

2.3

2.4

2.5

2.6

2.7

2.8

3. 2

4.

2