1 Tobacco Addiction and Nicotine Dependence 2 Nicotine

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

Statistics of Hong Kong 793, 200 daily & occasional smokers in 2006, or 14% of population aged 15 or over n Of 2006 population, 24. 5% of men and 4% of women are every day smokers n 59. 6% of daily smokers started smoking before age 19 n Men on average smoked 14 cigarettes a day, women smoked 10 cigarettes a day n 2

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

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

Nicotine n n 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 5

Nicotine n n 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 n n n Acetylcholine Beta-endorphin Dopamine Noradrenaline Serotonin and others that mediate pleasure, arousal, elevated mood, appetite, and other desirable psychological states 6

Nicotine n n n 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 7

Nicotine n n n 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 8

Tar n n 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 9

Carbon monoxide n n n 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 10

Other chemicals in cigarette smoke 11

Risks of continued smoking Heart and circulation Cancers Coronary heart disease, heart attacks, arteriosclerosis Lung, mouth, nose and throat, larynx, oesophagus, pancreas, bladder, stomach, leukemia, kidney Respiratory Chronic bronchitis, chronic obstructive pulmonary disease, emphysema (swollen with air), recurrent infections in airways, loss in pulmonary functions Others Impotence, peptic ulcers, adverse effects on fertility 12

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Why it is worth giving up 14

Benefits of quitting n n n n 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 15

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

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

Cutting down n n n 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 19

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

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

How nicotine replacement therapy (NRT) works 22

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

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

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

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

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

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

Nicotine gum n Reference dosage and duration of use n n 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 n n n 25 pieces of 2 mg gum 15 pieces of 4 mg gum The optimal duration of use for most people is about 12 weeks 29

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

Nicotine gum n Tips for using nicotine gum Avoid acidic beverages such as coffee, juice or soft drink 15 minutes before or while using the gum n 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 n 31

Nicotine gum n Contraindications and Warnings n n n 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. 32

Nicotine gum n Side effects n n n n 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 33

Nicotine lozenge n n Product available Nicotinell® lozenge n 1 mg nicotine in a sugarfree mint flavoured base 34

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

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

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

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

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

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

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

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

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

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

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

Nicotine patch n Tips for using nicotine patch n n n 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 46

Nicotine patch n Tips for using nicotine patch n n n 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 47

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

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

Nicotine inhaler n n 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 50

Nicotine inhaler Inhalation causes air saturated with vaporized nicotine to be drawn into the upper respiratory tract n Absorption occurs in the buccal mucosa n Useful for people who miss the hand-to-mouth action of smoking n 51

Nicotine inhaler Product available n Nicorette® inhaler n 10 mg nicotine in porous polyethylene catridges packed in closed blister trays n With reusable mouthpiece inhaler n 52

Nicotine inhaler n How supplied Each cartridge contains 10 mg nicotine n Continuous puffing (e. g. 3 to 4 times a minute), the cartridge can last for about 20 minutes n 53

Nicotine inhaler n Which smokers are most suitable Highly behavioural-dependent smokers n Smokers of 20 or less cigarettes per day n Those with dental problems or cannot chew gum or suck lozenge n 54

Nicotine inhaler n Reference dosage and duration of use Initial treatment period is normally 3 months n Gradually reduce dosage during next 6 to 8 weeks n Use beyond 6 months is not recommended n 55

Nicotine inhaler n Instructions for the use of Nicotine Inhaler n n n Pull apart the two sections of the inhaler Place a cartridge inside the inhaler Re-assemble the inhaler. As you push the two sections together, the inhaler pierces the seal on each end of the cartridge 56

Nicotine inhaler n Instructions for the use of Nicotine Inhaler Suck the mouthpiece. Breathe in gently drawing the air into the mouth and hold the air for a few seconds before breathing out. n One may also puff on the inhaler for several times (e. g. 3 to 4 times a minute) n 57

Nicotine inhaler n Tips for using the nicotine inhaler No difference between shallow puffing and deep inhalation n Works best at room temperature n One may feel a slight soreness or dryness in mouth and throat in the first few days. Drink more water to relieve the sensation n Avoid acidic beverages such as coffee, juice or soft drink 15 minutes before or while using the inhaler n 58

Nicotine inhaler n Tips for using the nicotine inhaler Nicotine strength is reduced when the sealing is broken n Open cartridges should not be used the next day n Cartridges contain nicotine even after use and should be disposed of as normal household waste out of the reach of children n Always keep cartridges and inhaler in closed plastic container provided when not in use n 59

Nicotine inhaler n Side effects Minor mouth and throat irritation n Cough n Rhinitis n n Tolerance to irritating effects usually occurs within a day or two 60

Other nicotine replacement therapy dosage forms n Other nicotine replacement therapy forms (not available in Hong Kong) Nicotine sublingual tablet n Nicotine nasal spray n 61

Nicotine sublingual tablet n n Nicorette® microtab 2 mg microtab packed in blister disks With dispenser to assist in removing the tablets from the blister To be dissolved under the tongue and NOT swallowed or chewed n First-pass effect will decrease the amount of nicotine 62

Nicotine sublingual tablet n Dosage < 20 cigarettes per day: 1 microtab every hour n > 20 cigarettes per day: 2 microtabs every hours if required n Not more than 40 microtabs per day n Aim to reduce dosage after 12 weeks n Do not use microtabs for more than 6 months n 63

Nicotine nasal spray n n n Nicorette® nasal spray 0. 5 mg/spray nicotine Absorption of nicotine through the nasal lining 64

Nicotine nasal spray Delivers a peak level to CNS in 5 minutes n By far the fastest of all nicotine formulations (but still much slower than cigarettes) n May use the spray in each nostril up to twice in any hour n Do not use more than 64 sprays in any period of 24 hours n 65

Nicotine nasal spray n Side effects n n n n Transient burning and stinging of nasal mucosa Throat irritation Coughing Sneezing, rhinorrhoea Lacrimation Nausea Usually lasting only a few seconds, and diminishing after about a week 66

Nicotine replacement therapy (NRT) Available without prescription at pharmacy n Requires strong will to quit n Must not smoke while using NRT ? n Does not “replace” tobacco, just a less harmful substitute to tobacco n Aim at n Sufficient duration of therapy n Tapering down nicotine at regular time intervals n 67

Can anyone use NRT? n Caution in patients with n n n n Cardiovascular (hypertension, arrhythmia, severe or worsening angina, during immediate post-myocardial infarction period) Peripheral vascular diseases Renal or hepatic insufficiency Diabetes Peptic ulcer Thyroid disorders Elderly, pregnancy and lactation 68

Pregnancy and NRT n n Nicotine is classified as pregnancy category D drug by the FDA Pregnant smokers should always be advised to stop smoking completely without using NRT Despite potential risks, use of NRT during pregnancy is probably safer than smoking in selected patients who are unable to quit using non-pharmacological methods alone Pregnant smokers should always seek medical consultation on smoking cessation 69

Key points for NRT A minimum of 6 weeks initial treatment period n Highlight the importance of strong will and gradual reduction in dosage n Differentiate the symptoms of withdrawal from side effects of nicotine therapy n Cautions, contraindications and pregnancy n 70

Advice on NRT n n Advise them to pick a Quit Day, a not-too-distant date when they will give up smoking completely and start using NRT Suggest that they ask a friend to give up smoking with them. Sharing a goal with someone else will help them know they're not alone Tell them to get rid of temptation by throwing out any cigarettes or other smoking materials and by avoiding smoky places like pubs. Suggest that they ask smokers they know not to offer them cigarettes Tell them to take it one day at a time. They should see each smoke-free day as an achievement 71

Advice on NRT n n Advise them to keep busy whenever they feel the urge for a cigarette. Remind them of the money they'll save when they give up buying cigarettes. Suggest they put this money aside in a pot labelled 'Cash not ash' until they have enough to reward themselves with a treat Advise against replacing cigarettes with food - ex-smokers often put on weight when they've given up. If your customer does want to diet, suggest that they concentrate on giving up smoking first, for about a month say, and then think about dieting. Reassure them that if at first they don't succeed they can try again with NRT at a later date. Most successful long-term exsmokers had to try to stop several times. 72

Non-nicotine replacement therapy n FDA-approved n n Bupropion Other non FDA-approved medications Clonidine n Nortriptyline n 73

Bupropion n n Bupropion (Zyban®) A medication originally developed and marketed to treat depression under the name of Wellbutrin® The first non-nicotine medication shown to be effective for smoking cessation and indication approved by the U. S. Food and Drug Administration (FDA) Available in Hong Kong upon a prescription 74

Bupropion n Mechanism of action Dopaminergic-noradrenergic reuptake inhibitor n Inhibit weakly the neuronal uptake of dopamine, noradrenline and serotonin but does not inhibit monoamine oxidase n Its mechanism in enhancing the ability of patients to abstain from smoking is unknown n n Product available n 150 mg sustained release tablet 75

Bupropion n Dosage Treatment should begin 1 week before patient stops smoking n 150 mg in the morning for 3 days, then increase to 150 mg twice daily for 7 -12 weeks n Maximum daily dose 300 mg n Can be used alone or with nicotine replacement therapy n 76

Bupropion n Side effects n n n n n dry mouth difficulty sleeping headache decreased appetite dizziness sweating nausea increased or irregular heart beat agitation / anxiety These side effects usually lessen with continued use of the medication 77

Bupropion n Contraindications and warning n n n n n Seizures (or taking medication that might increase the likelihood of having a seizure) Epilepsy (or a family history of epilepsy) Significant head trauma Stroke Brain tumour Brain surgery Anorexia or bulimia Taking monoamine oxidase inhibitor (MAOI) within the previous 14 days Patients undergoing abrupt discontinuation of alcohol or sedatives (including benzodiazepines) 78

Bupropion n Points to note Patients should be made aware that Zyban® contains the same active ingredient as Wellbutrin® n Significant drug interactions (CYP 450 2 D 6) n n Enzyme inducing anticonvulsants e. g. phenytoin, carbamazepine, phenobarbitone may decrease bupropion levels n Possible drug interactions, e. g. n Fluoxetine may decrease bupropion levels n Bupropion may increase levels of imipramine 79

Clinical efficacy of first line FDA approved agents 80

Success Rate and Evidence Rating Single therapies Brief physician advice Telephone counseling Self-help materials Nicotine patch Nicotine spray Nicotine inhaler Nicotine lozenge Nicotine gum in highly dependent smokers Bupropion SR Evidence rating A Quit rate at 6 months (%) 2 -10 A B 5 -19 7 -27 A A 8 -21 30 A A 23 24 A 21 -30 81

Success Rate and Evidence Rating Combination therapies Evidence rating Nicotine patch plus nicotine B gum Nicotine patch plus nicotine B spray Nicotine patch plus nicotine B inhaler Niotine patch plus B bupropion Quit rate at 6 months (%) 28 37 (at three months) 25 35 82

Second line pharmacotherapy n Clonidine (Catapress®) Non-FDA approved n Centrally acting alpha 2 -adrenergic agonist that reduces sympathetic outflow from CNS n Oral 0. 1 mg twice daily or transdermal 0. 1 mg daily n Side effects include dry mouth, sedation, dizziness, constipation n 83

Second line pharmacotherapy n Nortriptyline (Pamelor®) n n n Non-FDA approved Tricyclic antidepressant Initiated 10 days before quit date Oral 25 mg daily, increasing gradually to target dose 75 – 100 mg daily Side effects include sedation, dry mouth, blurred vision, urinary retention, light-headedness, tremor Caution in patients with cardiovascular diseases because of risk arrhythmias and postural hypotension 84

Nicotine withdrawal symptoms and management 85

Nicotine withdrawal symptoms n Cravings An intense desire to smoke as the body is missing the nicotine fix n Craving will lesson over a few weeks n Try NRT and or these tips: n n Take a few long, low, deep breaths n Drink a glass of water 86

Nicotine withdrawal symptoms n Coughing, dry mouth The lungs are clearing out the tar n Usually be worse at the start and improve quite quickly n Warm drinks can ease the cough n A sign that lung functions are recovering n 87

Nicotine withdrawal symptoms n Hunger n May feel extremely hungry due to n Changes in metabolism n Food tastes better after quitting smoking Put together a “survival kit” of fruits and vegetables n Carry chewing gum and drink lots of water n 88

Nicotine withdrawal symptoms n Bowel changes May suffer from constipation n Will soon settle down n Drink plenty of water n If constipated, try to incorporate more fibre into the diet by eating more cereals, fruits and vegetables n 89

Nicotine withdrawal symptoms n Trouble sleeping Nicotine leaving the body can disturb sleep patterns n Normal sleeping patterns will return in two or three weeks n Get more physical exercise and fresh air n Decrease consumption on tea, coffee and other stimulating drinks n 90

Nicotine withdrawal symptoms n Dizziness Happens when more oxygen starts getting through to the CNS when the effect of carbon monoxide wanes n Any dizziness will be gone after a few days n 91

Nicotine withdrawal symptoms n Mood swings, poor concentration, irritability Signs of nicotine withdrawal as the body is missing the stimulating effects of smoking n Coping mechanisms that work n Warn your family and friends, and ask for support n 92

Role of healthcare professionals in smoking cessation 93

The Five A’s Model for Facilitating Smoking Cessation Ask about tobacco use during every visit Include questions about tobacco use when assessing the patient’s vital signs Advise all smokers to quit Advice should be clear, strong and personalized Assess the patient’s willingness to quit Ask how motivated patient is to quit smoking, then determine appropriate step Assist the patient in his or her attempt to quit Help the patient make a quit plan, provide basic information about smoking and cessation, recommend pharmacotherapy and self-help material Arrange follow-up contact First follow-up should occur within the first week and second within the first month; can be by telephone, e-mail, or in person 94

What we can do to help smokers Advise smokers to quit n Assess the patient’s condition and suitability for smoking cessation aids n Recommend suitable dosage form of nicotine replacement therapy based on individual smoking habits and patterns n Provide detailed counselling on correct use of products n 95

What we can do to help smokers Draft a plan of gradual tapering and duration of nicotine replacement therapy n Monitor progress n Suggest non-drug measures n Provide emotional support n Arrange follow-ups n 96

Assessing level of care in smoking cessation 97

Assessing level of care in smoking cessation 98

People who successfully stop smoking… n n n n Really want to stop Understand why they smoked in the past Put time and effort into planning the attempt Know what to expect when they stop smoking Have support and encouragement Take one day at a time Plan ahead to avoid temptation See themselves as non-smokers 99

Make the first step to quit Set a quit date, get support from your family and friends n Dispose of all cigarettes, ashtrays and lighters n Stay away from smoking situations n Seek information from health professionals n 100

Most people start smoking again because… n n n n They thought they could get away with having ‘just one’. They hadn’t thought about their smoking triggers, and got caught out. They didn’t do enough planning and preparation. They didn’t work out other ways of handling stress. They hit a bad patch or a pressurized day. They put on weight. They thought of themselves as ex-smokers, not nonsmokers. 101

Sample of calculation on cost of smoking (UK) 102

My smoking diary Filling in a diary sheet will help you think about your smoking patterns n Try to do it over the course of a few days n Understand when and why you smoke n Plan what you can do at those times instead of smoking will help you get through the first few days without cigarettes n 103

My smoking diary 104

The “quit date” planner 105

Investigating your smoking habits 106

How to get through those tricky times Start a new project n Take a few slow, deep breaths n Go for a quick stroll (to walk in a relaxed and slow manner) or even just into another room n Drink a glass of water n Talk to a friend about how you’re feeling n Refer to the list of reasons you have for stopping n 107

Not ready? n n n Remember why you want to be a non-smoker. Try copying your reasons for quitting on to a card and carry it with you, so you can read them if you get tempted. Check through your ideas on handling the first week, and practise some of those new habits before your quit date. Make sure you’re fully prepared, and ready to manage without smoking. Lots of people fail because they rush into quitting before they’re really ready. If you’ve tried giving up before, think about what happened and how you felt. You can use your past experiences to help you cope better this time. 108

5 Ds to tackle craving Declare that you have quitted n Delay in getting a cigarette for a few minutes by deep breathing and drinking plenty of water n Distract yourself from thinking about smoking by doing something else like making a phone call or keeping yourself busy n 109

If you’ve just had a cigarette n n n n Make the decision to stop again immediately Throw away any remaining cigarettes Call a friend or the Smoking Helpline Go outside, or into a different room – get out of the situation that made you want to smoke Remember why you wanted to stop smoking in the first place Try to handle the ‘situation’ without another cigarette Keep telling yourself, ‘I can choose not to smoke’ 110

To sum up… 111

Thinking about giving up - Ten top tips n n n Contact your local Stop Smoking Service for practical help and advice from trained specialists Plan ahead to help you cope with stressful situations. Pick a quit date that will be stress-free, and stick to it. Take it one day at a time, and congratulate yourself every day. Pair up with someone else who wants to stop so you can support each other 112

Thinking about giving up - Ten top tips n n n Use Nicotine Replacement Therapy (NRT) or bupropion (Zyban) to help you manage the cravings At first, avoid situations where you might be tempted to smoke Keep track of the money you’re saving – and treat yourself! There’s no such thing as having ‘just one’ cigarette Think positive – you CAN do it! 113

Stay positive. Keep telling yourself, “I don’t smoke” and most importantly, be very, very proud of yourself! 114

Where smokers can get help from 115

Department of Health Regularly conducts smoking cessation activities in various service units including chest clinics, elderly health centres, etc. n Introduction of nicotine replacement of therapy in the Education and Training Centre in Family Medicine (Ngau Tau Kok) n DH smoking cessation hotline 2961 8883 n 116

Hospital Authority Smoking Counselling and Cessation Centres n Established in some hospitals / GOPCs from different clusters n Detailed counselling and nicotine replacement therapy trials provided by pharmacists and/or nurses n Breath carbon monoxide monitoring n HA smoking cessation hotline 2300 7272 n 117

Web resources from organizations - Hong Kong n Tobacco Control Office, Department of Health n n Hong Kong Council On Smoking & Health (COSH) n n http: //www. tobaccocontrol. gov. hk/chi/ http: //www. smokefree. hk/ Action on Smoking or Health n http: //www. ash. org. hk/ 118

Web resources from organizations - Overseas n Giving Up Smoking (UK) n n Action of Smoking and Health (US) n n http: //www. ash. org/ American Lung Association n n http: //www. givingupsmoking. co. uk/ http: //www. lungusa. org Tobacco Free Initiative (TFI) n http: //www. who. int/tobacco/en/ 119

Thank you 120