SMOKING CESSATION

DR. SHARIFAH NAJWA BINTI SYED MOHAMAD

FAMILY MEDICINE SPECIALIST AND LECTURER
FPSK, USIM
 AT THE END OF THE SDL, YOU
SHOULD BE ABLE TO

• Identify patients who are addicted to smoking.

• Discuss the steps in handling smoking addiction.
• Discuss the role of family doctors in managing
smoking addiction.
 SOME FACTS ABOUT SMOKING IN
MALAYSIA

• NHMS 2015:
• Approx. 23% of Malaysians (15 years and above) were smokers (almost 5 million in
numbers)
• Of these, about 60% of current smokers in a day smoked 15 sticks or above.
• The number of Malaysian adolescents (aged 13 to 17) who smoked is close to 300,000
in 2017, which is 13% higher than in 2012.
• Due to these numbers, the National Strategic Plan For Tobacco Control was
implemented.
CONTENTS IN A CIGARETTE
 DISEASE RELATED TO SMOKING
WORLDWIDE

• Cancers esp. lung cancer, others: oral cancers,

throat cancers
• Cardiovascular disease i.e. MI, stroke, vascular
problems
• Chronic obstructive pulmonary disease (COPD)
 NATIONAL STRATEGIC PLAN FOR
TOBACCO CONTROL

• Vision: Malaysia as a tobacco free nation by 2045

• Mission:
• Children born in 2009 will be free from all forms of smoking habits
• Community empowerment to denormalise smoking habit
• 100% of public places will be gazzeted as non-smoking area

• SO HOW CAN THIS BE ACHIEVED??

 QUIT SMOKING SERVICES

• Quit smoking clinics / services implemented since 2000

• Health clinics: most health clinics with FMS
• Hospitals: psychiatry clinics / dedicated team
• mQuit line: collaboration between KKM, USM, UM, pharmacies,
Johnson & Johnson’s
 CLASSIFICATION OF SMOKERS

• Patient uses tobacco and is now willing to make a quit

attempt
• Patient uses tobacco but is now not willing to make a quit
attempt
• Patient once used tobacco but has since quit
• Patient never regularly used tobacco.
 WHY DO PEOPLE SMOKE?

Immediate effects: Long term effects:

• Calmness • It makes more glucose in your
• Pleasurable sensations body

• Feeling relaxed and euphoric • It dulls your senses

• More focus and energy • Decreases your appetite

• Drops your skin temperature
HOW TO IDENTIFY SMOKERS?
 CPG RECOMMENDATIONS

Recommendations Grade

Ask and document smoking status for all patients C

Use individual, group and telephone counselling approaches, or in combination A

for smoking cessation interventions.

Arrange a minimum of six to eight face to face follow-up sessions for smoking A
cessation interventions in 6 months
 HOW TO TEST LEVEL OF
ADDICTION / DEPENDENCE?

Fagerstrom Test for

Cigarette Dependence
- - English version
- - Malay version
 IS YOUR PATIENT READY TO QUIT?

Pre-
Contemplation
Adapted from contemplation
Prochaska and Di Clemente
(1983) Stage of
change
Action
Relapse

Maintenance
IF THE PATIENT IS NOT READY TO
QUIT
ALL SMOKERS ATTEMPTING TO QUIT SHOULD BE OFFERED
PHARMACOTHERAPY, UNLESS CONTRAINDICATED

• Pharmacotherapy including
combination of NRTs or NRT+NNRT
• Behavioral intervention
• Combined pharmacotherapy and
behavioral intervention
 FACTSHEET ABOUT PHARMACOTHERAPY
AND SMOKING CESSATION - NRT

• No need for prescription – Group C medications, under Poison’s Act

1952
• All NRT products roughly double a person’s chance of stopping
compared to placebo
• 2NRTs are better than one
• Using NRT shortly before quit date may increase success rate
• People who need NRT for more than 12 weeks can continue to use it
• 4 different NRTs available in Malaysia: patch, gum, lozenges,
inhalator (most commonly used: patch and gum)
 FACTSHEET ABOUT PHARMACOTHERAPY
AND SMOKING CESSATION - VARENICLINE

• At least doubles a person chance of stopping smoking

• Pregnant or breastfeeding women and people under 18 years old
cannot use varenicline
• Duration: 12 weeks
• Common adverse effects: nausea, abnormal dreams and sleep
disturbance. More serious: CVS events, depression, suicidal
ideation/suicide but are uncommon.
• If someone using varenicline develop a change in mood/behavior
– change the medication.
 FACTSHEET ABOUT PHARMACOTHERAPY
AND SMOKING CESSATION - BUPROPION

• An atypical antidepressant that reduces severity of tobacco

withdrawal and approx. doubles a person’s chance of stopping
smoking
• Should be started 1 week before quit date and use it for at
least 7 weeks
• Pregnant or breastfeeding women cannot use it
• Common side effects: dry mouth, insomnia, headache. Seizure
has been rarely reported, and depression has been reported in
some people.
 WHAT TO CONSIDER WHEN
PRESCRIBING?

• Cost
• Availability
• Suitability with co-morbids
• Occupation
• Patient’s preference if applicable
 SPECIAL POPULATIONS TO CONSIDER

• Females
• Pregnant or breastfeeding women
• Psychiatric patients
• Children/adolescent
• Elderly
 RECOMMENDATIONS FOR FEMALES

• Similar treatment shout benefit both men and women

• Barriers:
• Under recorded smoking status -> lack of intervention
• Weight control issues
• Hormonal cycle
• Stress smoking
• What can improve female smokers to quit:
• Social support
• Physical activity
• Customised intervention modules for women, especially for those who are pregnant
 RECOMMENDATIONS FOR PREGNANT /
BREASTFEEDING WOMEN

Recommendation Grades of
recommendation

Offer multi-sessions behavioural smoking cessation A

interventions to all pregnant and breastfeeding women
who smoke
RECOMMENDATIONS FOR
PSYCHIATRIC PATIENTS
 RECOMMENDATIONS FOR CHILDREN
AND ADOLESCENTS

• Youths smoking from young age are likely to be regular smokers of tomorrow.
• Many smokers started smoking before the age of 18 years old (90%).
• Must screen paeds/adolescent patients and their parents regarding smoking – as parents who
smoke become a model to their children.
• Lower SE status, peer pressure, low self esteem, poor academic performance and behavioral
problems play a role in their choice to smoking habit.
• Counselling and behavioural modification interventions are effective – modified according to
their age.
• NRT or bupropion SR may be considered when there is evidence of nicotine dependence and
desire to quit.
 RECOMMENDATIONS FOR ELDERLY

• Smoking cessation plays a great role in reducing cardiovascular related events and
mortality in the elderly.
• Methods are similar – using similar treatments as for younger age groups.
• Elderly smokers with co-morbidities and psychological distress are more likely to stop
smoking compared to those who are well with no psychological concerns.
 WHAT HAPPENS WHEN YOU QUIT
SMOKING?

• Cough and running nose • Constipation

• Skin on the lips will peel off • Angry, irritated mood swings
• Swelling and bleeding of gums • Frustration
• Ulcer mouth • Restlessness
• Tingling sensations • Chest pain
• Sleep disturbance • Bodyaches
• Increase appetite • Night time awakenings
• Feel light headed
 HOW TO OVERCOME WITHDRAWAL?

• Apply the 5Ds

Deep breathing
Delay : 5 minutes exercise
Drink plenty of water 8-10 glasses
Divert your thinking (Do something else)
• Wash face and hands
• Cold bath
• Munch some thing
• Keep hands busy
Discuss with a friend
 ROADBLOCKS

- Withdrawal symptoms
- Fear of failure
- Weight gain
- Lack of support
- Depression
- Enjoyment of tobacco
- Cost of treatment
- Relapse
 SMOKING CESSATION AND WEIGHT
GAIN

• Weight gain usually follows smoking cessation – why?

• It is important to realise:
• Note the benefits of smoking cessation are still more than risks of weight gain
• Recommend healthy lifestyle and balance diet to help control weight
• Sensible advice regarding quit smoking and weight control: guide patients to realise that
although weight control is important, quit smoking can increase their risks of lung diseases
including malignancies.
• Weight gain in those who quit is reported to be up to 15 kg (10%) with a mean of 4-5 kg
in 12 months.
• Physicians may consider agents that may delay weight gain during the smoking cessation
treatment, such as: Bupropion, fluoxetine, NRT (gum) and varenicline.
 HOW TO PREVENT RELAPSE – D.E.A.D.

• Delay – Deliberately delay the act of lighting up cigarette by doing

something else
• Escape – Escape any situation / environment that induce smoking
• Avoid – Plan to avoid situation / environment that induce smoking
• Distract – Distract the intention to smoke by doing relaxation
techniques, housework, spending time with family, etc.
 E-CIGARETTES

• What are e-cigarettes (EC)?

• Meant to help smokers to quit smoking – really??
• In 1963 Herbert A. Gilbert first patented the first smokeless, non tobacco
cigarette device.
• In 2003, Hon Lik (a Chinese pharmacist) invented the current e-cigarette device
using the liquid vaporization system. (after his father’s death of lung cancer)
• Very low evidence level studies have shown that e-cigarettes helped smokers to
abstain from smoking compared to placebo.
• Despite having potential, ECs role in smoking cessation still remains unclear.
(Malaysian CPG on tobacco use disorder, 2016).
WHAT DO ECS LOOK LIKE?
E-CIGARETTE LATEST UPDATES, UK
(2019)

What about Malaysia?

 FATWA REGARDING SMOKING

• Anyone wants to volunteer?

• Muzakarah Jawatankuasa Fatwa Majlis Kebangsaan Bagi Hal Ehwal Ugama
Islam Malaysia Kali Ke - 37 yang bersidang Kali Ke - 37 di Dewan Syura,
Tingkat 11 pada 23 Mac 1995 yang lalu telah membincangkan isu mengenai
“Hukum Merokok Dari Pandangan Islam” dan telah bersetuju untuk
memutuskan dengan jelas bahawa “Merokok adalah HARAM dari pandangan
Islam kerana padanya terdapat KEMUDHARATAN”.
 REFERENCES

• Malaysian CPG on Treatment of Tobacco Use Disorder (2016).

• https://ecigarettereviewed.com/nicotine-withdrawal, accessed on 21 August
2019
• https://www.cancerresearchuk.org/health-professional/awareness-and-preventio
n/e-cigarette-hub-information-for-health-professionals/safety
accessed on 24 August 2019