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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5536_Библиотеки_им_академика_М_И_Перельмана.pdf
Tobacco
accepted. The last reason is the excitement of experimenting with something that
is forbidden. In Massachusetts it is against the law for anyone under 18 years old
to smoke. Usually parents do not allow their underage teens to smoke. Therefore,
smoking becomes very attractive. It is exciting to get cigarettes and sneak away to
smoke without being caught.
Adults smoke for other reasons. They may have a lot of stress and pressures because
of economic and personal problems. They may be unemployed or working but not
making enough money to take care of themselves and their families. They may be
homeless, or they may be dealing with alcohol or cocaine/heroin addictions. Some
may be in bad marriages or relationships in which there is physical and/or verbal
abuse. All these people may smoke to feel relaxed or to give them energy while
going through a hard time.
239
Citation: http://vapesterdam.com/wp-content/uploads/2015/02/Why-Do-People-Smoke-02.
jpg
Whether young or old, some people smoke to control their weight. Smokers, on the
average, weigh seven pounds less than non-smokers. Smoking reduces a person’s
appetite. It lessens his/her sense of taste and smell. This could be why ex-smokers
gain weight after quitting cigarettes. Food tastes and smells so much better. Finally,
there are people who say they love to smoke. Smoking gives them pleasure. It just
makes them feel good.
Barriers to Assisting Smokers
The overall prevalence rate of smoking among the Romanian population aged over
15 years is approximately 27%, with a higher prevalence among men. According
240
to the World Health Organization (WHO), 77% of all deaths in Romania in
2008 were caused by diseases for which tobacco smoking is the main risk factor.
Smoking cessation prevents and slows down the progression of major diseases such
as cardiovascular and respiratory disease, cancer and diabetes. Family physicians
(FPs) are uniquely placed to intervene with patients who use tobacco and support
cessation. However, studies show that smokers who visit their primary care physician
for reasons other than smoking are rarely offered assistance to quit or even the
minimum intervention of ‘brief advice.
Until recently, smoking cessation support services was not available in Romania. In
2005, after the WHO Framework Convention was ratified, specific legislation began
to be adopted. In 2007, the Ministry of Health initiated the National Programme
against Tobacco Consumption, which included the Stop Smoking support programme.
This offered free training to any doctor interested in providing smoking cessation
support for their patients and financial incentives to become part of a national
network of centres where smokers could be offered free counseling and medication.
However, few FPs engaged with, or referred patients to, the programme: e.g., the
main author (CP) was the only FP involved in the programme over a 2-year period.
The reasons why FPs did not utilize this programme are unclear.
Illustrated Handbook of Drugs & Alcohol Related Health Issues
Citation: http://www.barriersdirect.co.uk/assets/0002/3034/classic_waiting_smoking_shelter.
jpg
Several studies describe the professional behaviour of Romanian FPs towards smokers
and highlight the lack of engagement in smoking cessation activities. In one study,
more than 70% of FPs knew about smoking cessation, but less than half applied
Tobacco
this knowledge in their own practices Interventions tended to be limited to brief
advice for patients with a diagnosed concomitant chronic disease, and few FPs
referred patients to smoking cessation specialists.
241
Citation: https://upload.wikimedia.org/wikipedia/commons/thumb/1/11/No_smoking_
symbol.svg/1200px-No_smoking_symbol.svg.png
Practice setting
While motivation and confidence to quit are important, one of the major barriers
to clinician effectiveness is the failure to identify most smokers in a practice or
clinical setting or to offer advice to those interested in quitting.
Patients
Around two thirds of smokers are interested in quitting, and half try to quit each
year. Despite the difficulty of quitting, 50% of people who have ever smoked
eventually successfully quit smoking. The success rate of those who use some form
of assistance is double that of those who try to quit on their own.
Smoking Cessation Guidelines
Various tools can be used by health care professionals in attempting to help smokers
quit:
■ Th e Five ‘A’s
■ CREATE (see below)
■ Decision Balance Worksheet
242
These tools should be used in the context of the concepts and techniques are:
■ Prochaska and DiClemente’s Model of Change
■ the principles of a patient-centred approach
■ techniques of motivational interviewing and brief intervention
Illustrated Handbook of Drugs & Alcohol Related Health Issues
The Five ‘A’s
The Five ‘A’s, developed by the US Department of Health and Human Services and
widely adopted is an evidence-based, rigorously evaluated framework for smoking
cessation in health care settings.
The Five ‘A’s stand for:
■ Ask
■ Assess
■ Advise
■ Assist
■ Arrange
The main components of the Five ‘A’s framework are described in Appendix H. For
each component there are brief, moderate and intensive strategies.
Brief strategies should take between 1–3 minutes. If time is very limited and it is
likely that the smoker could be seen again soon, spend the time available highlighting
the value of quitting; alternatively give the smoker a Quit line card.
Create
Create is an acronym representing a tool which can assist health care professionals
to identify smoking status in all patients and provide assistance to those who are
interested in quitting.
Decision Balance Worksheet
Not all smokers wish to quit. The model of change is a useful framework to
understand the process involved in changing health related behaviour.
The Decision Balance Worksheet is a simple tool which assists the smoker to assess
their readiness to change. The health professional can help the smoker to complete
a decision balance, by working through the smoker’s own thoughts, beliefs and
feelings.
Pharmacotherapies
It is important to undertake a holistic approach to smoking cessation, so that
pharmacotherapy is not considered as a standalone treatment. Relapse prevention
Tobacco
incorporates a range of psychosocial strategies which may include pharmacotherapies.
Pharmacotherapies to assist with smoking cessation include:
■ nicotine replacement therapy (NRT)
■ other drugs such as bupropion, clonidine and nortriptyline
Pharmacotherapies can minimize withdrawal symptoms and double the likelihood
of the smoker successfully quitting. Pharmacotherapy should be considered for all
smokers who have evidence of nicotine dependence.
243
Nicotine replacement therapies (NRTs)
NRTs help the smoker to minimize the effects of nicotine withdrawal. They are
available without prescription from pharmacies. A number of smokers have tried
these agents; however many have had insufficient instruction and assistance to use
them effectively
Choice of agent depends upon:
■ patient preference
■ pattern of any previous withdrawal symptoms
■ combinations of agents may be necessary if patients are experiencing
breakthrough nicotine withdrawal
■ regular review is essential to tailor the dose and monitor progress
■ it is important to emphasize that the smoker should abstain completely
from smoking while using NRT
Their doses and duration, side effects and contraindications.
Bupropion
Bupropion is a prescription oral drug used to treat depression and help patients
quit smoking. It works by increasing levels of certain neurotransmitters in the
brain, promoting pleasurable feelings and lessening withdrawal symptoms from
nicotine. When the drug is taken daily exactly as directed by a physician, patients
usually start feeling better within about one month. The risk of serious side effects
or overdose is relatively low, but potentially life-threatening reactions can occur if
the drug is abused.
Antidepressants and anti-smoking aids such as bupropion are classified as dopamine
and norepinephrine reuptake inhibitors. Depression and withdrawal symptoms are
closely associated with a lack of dopamine and norepinephrine in the brain, and
bupropion helps to increase levels. The drug blocks the sites on neural cells that
normally reabsorb the neurotransmitters, allowing them to build up in the brain. With
more dopamine and norepinephrine available, anxiety decreases while pleasurable
feelings increase.
244
Citation: http://images.wisegeek.com/doctor-breaking-cigarette.jpg
People who take bupropion as a smoking cessation aid are allowed to keep smoking
for the first week or two of treatment. Over the course treatment, urges to smoke
and withdrawal symptoms tend to lessen and eventually disappear completely.
Some patients are instructed to use nicotine patches or gum in combination with
bupropion, but the use of other aids must be recommended by the prescribing
doctor to prevent adverse reactions.
Illustrated Handbook of Drugs & Alcohol Related Health Issues
A person who suffers from clinical depression may be prescribed a generic version
of bupropion or the brand name version Wellbutrin. As an anti-smoking aid, the
drug is commonly marketed as Zyban. Both forms of the medication are available
in extended-release capsules containing up to 150 milligrams. A doctor normally
starts a patient on a low dose of the drug and gradually increases dosing amounts
over a few days or weeks. Effective dosages vary between patients, and doctors
take care to determine the appropriate level to maximize the drug’s effects while
minimizing the chances of adverse reactions.
Citation: http://images.wisegeek.com/man-in-pink-shirt-stressed-at-desk.jpg
Tobacco
Patients who take bupropion are at risk of experiencing a number of side effects, most
of which are mild and short-lived. Many people have headaches, mild insomnia, and
loss of appetite when taking the drug. Less commonly, an individual can experience
dizzy spells, migraines, nausea, and skin rashes. The medication can occasionally
cause tremors, seizures, or mood swings. Patients who experience minor side effects
should continue taking their medications and contact their doctors to determine
if dosages need to be adjusted. Serious side effects need to be addressed at an
emergency room to prevent severe health complications.
Bupropion offers an alternative to NRT. Smokers start bupropion 7 days before the
negotiated quit date and take it for 7 weeks.
Absolute contraindications are:
■ previous seizures or significant risk of seizures
■ history of bipolar disorders
■ history of eating disorders (bulimia, anorexia)
The doses and duration, side effects and contraindications associated with bupropion
Clonidine and nortriptyline, while effective, should be considered as second line
agents as they have more troubling side effects.
245
How Effective Is Bupropion for Smoking Cessation?
The use of bupropion for smoking cessation has been shown to be very effective in
helping patients stop using cigarettes. In fact, those who use buproprion are twice
as likely to be successful than those who try and quit cold turkey. It is equally
effective as most nicotine replacement therapies. The exact level of effectiveness, as
with any drug, will typically depend on the patient. Those who have been smoking
for many years may find it harder to quit than those who have not been smoking as
long, as well as those who smoke an unusually large number of cigarettes per day.
Bupropion is the first non-nicotine containing drug used to help smokers quit. The
exact way bupropion for smoking cessation works is not entirely understood, but
it helps relieve the feelings of withdrawal symptoms related to suddenly quitting
tobacco use, and it can also curb cravings for tobacco in most patients. This
makes patients less likely to want a cigarette, and the body eventually becomes
less nicotine dependent.
The use of bupropion for smoking cessation can be combined with other antismoking remedies. Since this drug doesn’t contain nicotine or tobacco, it is safe for
use with nicotine patches, gum, or inhalers. Electronic cigarettes are also usually
safe for use with bupropion. Many patients will have better results when multiple
anti-smoking methods are used in combination with one another.
246
Illustrated Handbook of Drugs & Alcohol Related Health Issues
Citation: http://images.wisegeek.com/woman-with-nicotine-patch-on-her-arm.jpg
Most patients are prescribed bupropion for smoking cessation several weeks before
the use of tobacco has ceased. This allows the drug to accumulate in the body so
that it is more effective. It is then used for several weeks, or even months, after
the last cigarette has been smoked. For most patients, it’s safe to take it for up to
one year.
Bupropion is also used as an anti-depression under a different brand name. For
those who smoke to relieve stress or anxiety, it may also be beneficial in that way
for those who want to quit. Patients who suffer from depression or other conditions
should discuss options with their doctors. It should not be assumed that taking
bupropion for smoking cessation will automatically treat depression as well, since
dosages and instructions may be different for each use.
Side effects can occur with bupropion, including dry mouth and insomnia. These
are usually temporary and clear up on their own without additional treatment. Rarer
symptoms, like stomach upset, can also occur. If any side effects are especially
troublesome, or if they do not go away within a few weeks of taking the drug, a
doctor should be notified.
Tobacco
247
What Factors Affect a Sufficient Bupropion Dose?
The main factors affecting the bupropion dose used are tolerance, response and the
clinical indication for which it is being used. Other factors which may be taken into
account include the liver and kidney function of the patient which, if compromised,
may necessitate a lower dosage. There are a number of different pharmaceutical
preparations of bupropion available immediate-release, slow-release and extendedrelease and which one is used will determine the frequency of dosage of the drug.
Bupropion is an antidepressant drug which is used to treat depression, seasonal
affective disorder and in the cessation of smoking. It works by blocking the reuptake
of noradrenaline and dopamine in the brain, which are chemical neurotransmitters
involved with mood. Bupropion may be known by different trade names in different
countries, according to manufacturer, and in most countries is available by prescription
only.
The sufficient bupropion dose for depression will be established by the treating
doctor on a case-by-case basis. Usually the drug is started at low dose and increased
slowly with the doctor monitoring response and tolerance. The bupropion dose will
usually be taken three times a day for the immediate-release preparation, twice a
day for the sustained release preparation and once daily for the extended-release
preparation. The prescribed dose should never be exceeded without discussion
with the doctor.
Citation: http://images.wisegeek.com/woman-in-grey-sweater-upset.jpg
When using the drug to aid stopping smoking, the bupropion dose is usually
started as a once daily dose and increased to twice daily after some days. The
drug is started while the person is still smoking but a quitting date is established
248
before taking the first bupropion dose, usually within a week or two of starting
treatment. The full course of treatment is usually two to three months and should
be accompanied by non-drug supportive measures.
In patients who have hepatic (liver) dysfunction, bupropion may be contraindicated
or a reduced bupropion dose or increased time between dosing may be necessary.
Any underlying clinical conditions and other medications, including homeopathic,
complementary and over-the-counter medications, should be discussed with the
prescribing doctor before starting treatment. Interactions may occur between
bupropion and other medicines.
As with any medication, adverse effects may occur. These may include agitation,
insomnia, headache and nausea. Seizures have also been reported, so bupropion is
contraindicated in patients with pre-existing seizure disorders. The lowest effective
dose will be used to minimize the possibility of adverse effects and medical advice
should be sought if they do occur.
Illustrated Handbook of Drugs & Alcohol Related Health Issues
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