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Protocol for smoking cessation

31 May, 2016

Dr. Satya Narayana Mysore


Problem statement and review of literature:


Historical aspects:

Archaeological excavations in Mexico and Peru have demonstrated the existence of tobacco since 3500 BC. Tobacco has been used in one form or the other since 8000 years probably originated from Calib.


Indian scenario:

The prevalence of smoking tobacco in India is 110 million and 3.2% are women. There has been increase in women who smoke from 5.3 million in 1980 to 12.1 million in 2012.

Institute of health metrics and evaluation data is in agreement with this. The global burden of disease is one million deaths a year and significant health loss in India.

It is estimated that by 2030, the premature death attributable to tobacco would double to 10 million death/year. It is estimated that death due to tobacco in developing countries will increase to 10 million deaths/year.

It is of great concern that the tobacco smoking in school children amongst 13 to 15 years old varies geographically from 3.3% in Goa to 62.8% in Nagaland.


The addiction potential of tobacco (Nicotine) – Mechanism and ways of inducing addiction.

Smoking is a highly efficient form of drug administration. Inhaled nicotine enters circulation and moves into brain quickly. “Rush” is the term to indicate the nicotine reaching brain due to rapid administration that reinforces the effects of the drug. Contrasted with this is the nicotine commercially marketed patches, release the drug slowly and risk of abuse is low. There is high degree of hereditability of cigarette smoking (>50%).

Nicotine Addiction, its Mechanism and ways of inducing addiction

Nicotine Addiction and it's mechanism


Patterns of smoking:

Nicotine is metabolised in the liver by enzyme CYP2A6.  The rate of nicotine metabolism varies in each individual. Slow metabolism of nicotine is associated with fewer cigarettes being smoked and vice versa. Tobacco smoking begins typically in adolescence with 80% of smokers by 18 years of age.

The positive reinforcements of smoking leading nicotine rush leads to an enhancement of mood and mental or physical functioning and avoidance of withdrawal symptoms.

Given the above smokers could be placed into two patterns;

  1. Peak seekers: smoke intermittently to boost the positive psychoactive effects of nicotine and prevent nicotine withdrawal effects.
  2. Trough seekers: Smoke on regular basis and constantly. This will keep the blood nicotine levels at a constant value. There will be elements of behavioural and physical dependence in this cohort.

Smokers with behavioural dependence. Usually smoke a few cigarettes and are able to quit with or without behavioural therapy.

Smokers with psychological dependence linked to psychoactive actions of nicotine; pleasure, improved cognitive performances, mood regulation, hunger and body weight calculations.

Smokers with physical dependence: The withdrawal symptoms that occur when trying to quit include irritability, anger and craving for cigarettes.

Behavioural issues and cues play a large role in continued smoking addiction.

Pattern of smoking also depends on workplace restrictions, social awareness, education and other variables.


Smoking cessation strategies

It is essential to first have all educational material that can clarify the risk of continued smoking. A didactic scare tactics are easily recognised by patients and is not an ethical practice. A brief clinical engagement is the first step.  Assess the willingness to quit.

Patient will be asked to set a date for quitting. This aims at voluntary behavioural exercise and provides the individual to strengthen the resolve towards smoking cessation.

A week or two before the “quit date” initiate Nicotine replacement therapy/bupropion/ varenicline.

Some patients may go “Cold Turkey” and altogether cease smoking without any aids. The patient or client is counselled to quit smoking altogether on the “quit date”.


Follow up:

It will be ideal for frequent but brief clinical consult. Schedule visit after taking into account the following factors.

  • Individual determination and continued abstinence.
  • Logistics of visit in view of work, commuting etc.
  • Web based tools using patient portal of hcl AVITAS.
  • AVITAS call centre may provide a “quit line approach”.


Behavioural interventions (WHO guidelines)

Tailor these hints to the individual patient. Suggestions include:

  • The Five Ds. Patients may find it useful to remember and practise the Five Ds
  • When confronted with the urge to smoke:
    • Delay, even for a short while
    • Drink water
    • Deep breathing
    • Do something different and
    • Discuss the craving with another person
  • write out a list of reasons to quit and display it prominently e.g. on the fridge
  • get rid of all tobacco products, ashtrays, lighters, matches, etc. from all areas which
  • you inhabit.
  • Clean all clothes in order to remove cigarette smell
  • Enlist the support of non-smoking friends, relatives, workmates
  •  change habits associated with smoking e.g. instead of smoking after meals, chew on a toothpick or change rooms
  • change the environmental cues, e.g. the telephone often causes a reflex action to smoke, move the telephone to another place to change the cue.
  • keep hands busy e.g. knitting, gardening, drawing, origami
  • change the daily routine in order to minimize association of tobacco with certain
  • activities or times of the day
  • sit in non-smoking areas
  • escape situations if a potential relapse cannot be avoided e.g. go to bathroom
  • deep breathe
  • positive self-talk
  • try to avoid stressful situations in the immediate period after stopping
  • substitute the urge to smoke with another activity eg going for a walk
  • try daily exercise, eg walking to keep self-occupied, to relieve stress and help
  • maintain positive frame of mind and to become fit
  • set aside the money normally spent on cigarettes to buy something as a reward
  • do not drink alcoholic beverages because these are associated with relapse
  • avoid, even temporarily, social situations normally associated with smoking.
  • Practise saying, “No thank you, I don’t smoke”
  • ask other smokers not to give cigarettes, offer to buy cigarettes or smoke in the
  • patient’s presence
  •  think positive and remember your reasons for quitting in the first place
  • view quitting as a day-at-a-time process rather than an immediate lifelong

Smoking cessation flow chart

Smoking Cessation flow chart

Adopted from WHO

Patient's instructions for nicotine replacement therapy

Adopted from WHO: