1. Tobacco Addiction and Nicotine Dependence 2. Nicotine Replacement Therapy and Treatment Approaches

1. 1. Tobacco Addiction and Nicotine Dependence2. Nicotine Replacement Therapy and Treatment Approaches

2. Statistics of Hong Kong • 793,200 daily & occasional smokers in 2006, or 14% of population aged 15 or over • Of 2006 population, 24.5% of men and 4% of women are every day smokers • 59.6% of daily smokers started smoking before age 19 • Men on average smoked 14 cigarettes a day, women smoked 10 cigarettes a day

3. Tobacco dependence Tobacco dependence = Pharmacological (nicotine) + Behavioural dependence (hand-to-mouth ritual)

4. What is in tobacco smoke • Tobacco smoke contains over 4,000 chemicals, including at least 50 that are known to cause cancer • Three of the main components are nicotine, carbon monoxide and tar • Nicotine is what makes smoking addictive, while carbon monoxide and tar can cause serious diseases

5. Nicotine • Powerful, fast-acting drug and is one of the most addictive substances on the planet • Most people who smoke become dependent on the nicotine they get from cigarettes • Nicotine has many complex effects on the body, including increasing the heart rate and blood pressure, and speeding up the metabolism • Nicotine also affects the mood and behaviour of the smoker

6. Nicotine • Nicotine acts as an agonist at nicotinic cholinergic receptors at the autonomic ganglia, neuromuscular junctions and in the brain • Nicotine’s positive reinforcing properties are believed to be the result of the release of neurotransmitters including • Acetylcholine • Beta-endorphin • Dopamine • Noradrenaline • Serotonin and others that mediate pleasure, arousal, elevated mood, appetite, and other desirable psychological states

7. Nicotine • Nicotine activates the dopamine reward pathway in midbrain, a network of nerve tissues that elicits feelings of pleasure • Immediately after inhalation, a bolus of nicotine enters the CNS, stimulating release of dopamine which induces nearly immediate feelings of pleasure, along with relief of symptoms of nicotine withdrawal • Rapid dose response reinforces repeated administration and perpetuates smoking behaviour

8. Nicotine • Chronic administration of nicotine has been shown to result in an increased number of nicotine receptors in specific areas of brain • Receptor upregulations leads to development of tolerance (repeated dose produce less of an effect than did the initial exposure) • Tobacco users become adept (highly skilled) at titrating their nicotine levels throughout the day to avoid withdrawal symptoms, to maintain pleasure and arousal, and to modulate mood

9. Tar • Sticky brown substance that stains smokers’ fingers and teeth yellowy brown • When a smoker inhales, about 70 per cent of the tar in the smoke stays in the lungs • Many of the substances in tar are already known to cause cancer • Irritants in tar can also damage the lungs by causing narrowing of the bronchioles, and damaging the cilia that help protect the lungs from dirt and infection

10. Carbon monoxide • A poisonous gas found in high concentrations in tobacco smoke • Large amounts can kill • Carbon monoxide lowers the oxygen in the bloodstream by up to 15 per cent, cutting down the efficiency of the lungs • Cells and tissues need oxygen to function efficiently • Carbon monoxide is especially harmful during pregnancy as it reduces the amount of oxygen carried to the womb and baby

11. Other chemicals in cigarette smoke

12. Risks of continued smoking

14. Why it is worth giving up

15. Benefits of quitting • Save money • Provide your beloved ones a smoke-free environment • Be free from the odour of smoking • Get rid of tar-stained teeth and fingers • Establish a healthy look • Improve your sense of taste and smell • Be less likely in getting heart disease, stroke or cancer

17. Ways to stop smoking • Cold turkey • Stopping smoking immediately and completely • Cutting down • Reducing the number of cigarettes over a period of time • If the period is too long, it may make giving up more difficult • Pharmacotherapy • As assistance to smoking cessation • Alternative treatments • Hypnosis, acupuncture and complementary therapies may help • No formal evidence for efficacy

18. Cold turkey • Stopping without any kind of aid • Despite its addictive nature, nicotine does not hang around in body long (about 48 hours) once you have stopped smoking • Although physical symptoms can be more extreme in the early few days, they fade away within the first two or three weeks. • Most people give up smoking using this method

19. Cutting down • Smoke only half of each cigarette • Each day, postpone the lighting of first cigarette 1 hour • Decide to smoke only during odd or even hours of the day • Decide beforehand how many cigarettes to smoke during the day. For each additional cigarette, give a dollar to favorite charity • Change the eating habits to help cutting down • Reach for a glass of juice instead of a cigarette for a "pick-me-up” • Cutting down can help quitting, but it's not a substitute for quitting

20. Pharmacotherapy • Pharmacotherapy in smoking cessation can be classified as • Nicotine replacement therapy • Non-nicotine replacement therapy

21. Nicotine replacement therapy (NRT) • Allow smokers to overcome the physiological dependence on nicotine by gradually reducing nicotine intake • Provides smokers with craving relief, but without the other harmful ingredients in tobacco

22. How nicotine replacement therapy (NRT) works

23. How nicotine replacement therapy (NRT) works • Nicotine from NRT is well absorbed • Onset of action of NRT is not as rapid as cigarette smoking • Patients who use NRT become less habituated to the nearly immediate, reinforcing effects of nicotine

24. Nicotine replacement therapy (NRT) • Clinical efficacy • Reduces physical withdrawal symptoms and lets one concentrate on the other changes needed to make as one quits smoking • Studies have shown that the use of NRT could double the chance of success • Up to 6 times if receiving thorough counseling • However, the most important factor for successful smoking cessation still lies on the will to quit

25. Includes Nicotine gum Nicotine patch Nicotine inhaler Nicotine sublingual tablet (available in other countries) Nicotine nasal spray (available in other countries) Nicotine replacement therapy

26. Nicotine gum • Nicotine in an ion-exchange resin in gum base • Absorption occurs at the buccal mucosa • Intermediate in CNS delivery speed • Serum nicotine levels reach a peak in 20-30 minutes

27. Products available Nicotinell® Fruit/mint chewing gum 2 mg, 4 mg Nicorette® Ordinary/freshmint chewing gum 2 mg, 4 mg Nicotine gum

28. Nicotine gum • Which smokers are most suitable • Smokers with an irregular smoking pattern • Provides oral gratification • 4 mg gum most suitable for highly dependent smokers • More than 20 cigarettes per day • First cigarette within 20 minutes of waking

29. Nicotine gum • Reference dosage and duration of use • For people who smoke more than 20 cigarettes per day, they may require 4 mg preparation • For those who smoke less than 20 cigarettes per day, the 2 mg preparation is usually sufficient • Initial dosage 8 to 12 pieces per day • Daily dosage should not exceed • 25 pieces of 2 mg gum • 15 pieces of 4 mg gum • The optimal duration of use for most people is about 12 weeks

30. Nicotine gum • Instruction to use nicotine gum • “Bite-park” chewing method • Each gum can last for 30 minutes

31. Nicotine gum • Tips for using nicotine gum • Avoid acidic beverages such as coffee, juice or soft drink 15 minutes before or while using the gum • Correct usage of NRT is very important. Incorrect method of chewing not only affect the effectiveness of the nicotine gum, it may also cause side effects such as sore throat, hiccup or heartburn

32. Nicotine gum • Contraindications and Warnings • Nicotine gum should be avoided in individuals with recent myocardial infarction, unstable angina pectoris, serious cardiac arrhythmias, or active duodenal or gastric ulcers • Pregnant smokers should always be advised to stop smoking completely without using NRT • Use of nicotine gum by the pregnant smoker should only be initiated following advice from a physician.

33. Nicotine gum • Side effects • flatulence • Indigestion • Nausea • Unpleasant taste • Hiccup • Sore moth, throat and jaw • Correct use of the gum is important in maintaining sufficient nicotine levels while minimizing side effects

34. Product available Nicotinell® lozenge 1 mg nicotine in a sugar-free mint flavoured base Nicotine lozenge

35. Nicotine lozenge • Absorption occurs at the buccal mucosa • Intermediate in CNS delivery speed, similar to nicotine gum • Serum nicotine levels reach a peak in 20-30 minutes • Unlike gum, lozenge actually provides more nicotine because it dissolves completely, delivering the entire dose

36. Nicotine lozenge • Which smokers are most suitable • Smokers with low nicotine dependency (less than 20 cigarettes per day) • Also good for those who cannot chew gum, e.g. dentures • Instructions • Suck a lozenge until flavour becomes strong • Hide lozenge between the gum and cheek • Each lozenge lasts about 30 minutes

37. Nicotine lozenge • Reference dosage and duration of use • 1 lozenge every 1 to 2 hours • 8 to 12 lozenge per day • Not more than 25 pieces per day • Aim to cut down in 3 months • Not to be used for more than 6 months

38. Nicotine lozenge • Contraindications and warnings • Similar to nicotine gum • Side effects (due to swallowed nicotine) • Heartburn • Hiccup • Nausea • Headache

39. Nicotine patch • Transdermal delivery system • The skin patch delivers a steady dose of nicotine through the skin • This reduces craving for nicotine and lets one focus on changing the behaviors which associate with tobacco use

40. Nicotine patch • Delivers nicotine to CNS more slowly than other dosage forms • 6-8 hours to reach peak serum levels • Higher doses of transdermal nicotine appear to be more effective than lower doses • Largest strength and moderate strength patches for initial treatment • Lowest strength for tapering only

41. Products available Nicotinell TTS® 21 mg (30 cm2) 14 mg (20 cm2) 7 mg (10 cm2) per 24 hours Nicorette® 15 mg (Step 1) 10 mg (Step 2) 5 mg (Step 3) per 16 hours Nicotine patch

42. Nicotine patch • Nicotinell® TTS patch • 24-hour patch • Useful if patient usually gets up for a cigarette during the night • May disturb sleep • Nicorette® patch • 16-hour patch • For regular smokers

43. Nicotine patch • Which smokers are most suitable • Smokers with a regular smoking pattern • Moderately dependent smokers (10-20 cigarettes per day) • Those who prefer • The convenience of a patch • Not to chew gum or suck lozenge, e.g. dentures, dental problem • Those with gastric ulcer or diabetes • Those with low behavioural dependence

44. Nicotine patch • Tips for using Nicotine Patch • 16-hour patch • Keep the patch attached at all times except sleeping hours • Remove the patch before you go to bed • Apply a new patch in the morning • 24-hour patch • The patch should be attached at all times • Change it daily at a regular time

45. Nicotine patch • Tips for using nicotine patch • Apply to clean, dry and non-hairy sites on upper body including arms and back • Do not apply to inflamed or broken skin • Do not apply any sorts of cream, powder or medication over the same site of the patch

46. Nicotine patch • Tips for using nicotine patch • Gently press the patch onto the site you have chosen for 10 minutes • Avoid touching the adhesive side of the patch during application • Do not peel it off to check whether it is fixed or not • Usually the patch will not drop off even during bathing or swimming • If it comes off, apply a new one • Wash hands after application to avoid local contamination of the eyes

47. Nicotine patch • Tips for using nicotine patch • Daily change the patch site so as to avoid skin irritation • Wait for at least 3 days before using the same area again • Unnecessary prolonged application not only affects the effectiveness of the nicotine patch, it may also cause skin irritation • Before disposing a patch, fold it in half with the sticky sides together • Dispose patches out of reach of children

48. Nicotine patch • Reference dosage and duration of use • 16-hour and 24-hour patches to suit different people's needs • Treatment begins with • 15 mg (Step 1) or 10 mg (step 2) for 16-hour patch • 21 mg (30 cm2) or 14 mg (20 cm2) for 24-hour patch • Transfer to lower dose patch after 12 weeks then taper off

49. Nicotine patch • Side effects • Generally well tolerated • Patients discontinue nicotine patch because: • Pruritus at the patch site • Patient may be able to tolerate a different brand • Insomnia or vivid dreams • Remove the patch at bedtime (i.e. using the 16-hour patch) usually minimizes or eliminates sleep disturbances

50. The size and shape of the inhaler resembles a cigarette A replaceable cartridge that fits inside the inhaler releases small amount of nicotine when one inhales air through it Nicotine inhaler