E-Cigarettes Dan Vape PenggantiRokok ?

Dr Salmah Noordin

Pakar Perubatan Keluarga

Hulu langat

• Memahami isu tentang rokok

• Memahami isu tentang vape

• Mengetahui kajian tentang penggunaan vapeuntuk berhenti merokok

• Memahami prinsip terapi gantian

Kenapa perlu ganti ?

Pokok tembakau

Adakah kita boleh menjadi ketagihkepada tembakau?

• Nikotin- sejenis alkaloid yang terdapat dalamtembakau dan bertanggungjawabmenyebabkan ketagihan

Ketagihan Nikotin

• Bertindak di otak- ‘ reward pathway’

• Reseptor Nikotine acetylcholine di ransangdan merembeskan dopamine

• Merokok menyebabkan pengeluarandopamine dengan cepat

0

50

100

150

200

0 60 120 180

Time (min)

% o

f B

as

al D

A O

utp

ut

NAc shell

Empty

Box Feeding

Source: Di Chiara et al.

FOOD

100

150

200

DA

Co

nc

en

tra

tio

n (

% B

as

eli

ne

)

MountsIntromissionsEjaculations

15

0

5

10

Co

pu

latio

n F

req

uen

cy

Sample

Number

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

ScrScr

BasFemale 1 Present

ScrFemale 2 Present

Scr

Source: Fiorino and Phillips

SEX

Natural Rewards Elevate Dopamine

Levels

0

100

200

300

400

500

600

700

800

900

1000

1100

0 1 2 3 4 5 hr

Time After Amphetamine

% o

f B

as

al R

ele

as

e

DADOPACHVA

Accumbens AMPHETAMINE

0

100

200

300

400

0 1 2 3 4 5 hrTime After Cocaine

% o

f B

as

al R

ele

as

e

DADOPACHVA

AccumbensCOCAINE

0

100

150

200

250

0 1 2 3 4 5hrTime After Morphine

% o

f B

as

al R

ele

as

e

Accumbens

0.51.02.510

Dose (mg/kg)

MORPHINE

0

100

150

200

250

0 1 2 3 hr

Time After Nicotine

% o

f B

as

al R

ele

as

e

AccumbensCaudate

NICOTINE

Source: Di Chiara and Imperato

Effects of Drugs on Dopamine Levels

Nicotine addiction cycle

Tolerance and physical dependence

Nicotine abstinence produces withdrawals symptoms

Nicotine use to self-medicate withdrawal symptoms

Nicotine use for pleasure, enhance performance, mood regulation

Kenapa terus merokok ?

• Host: Addiction, genetic, family, mental illness

• Agen: mudah di perolihi

• Persekitaran : Occupation, Peer, CultureHost

AgentEnvironment

Selain ketagihan…

• 4000 7000 bahan kimia

• 40 adalah penyebab kanser

• 500 racun

Apa kita perlu tahu tentang E cig danVape

Apa itu E Cig dan Vape ?

E-liquid or E-juice

Propylene glycol (~66%) 2

Glycerin (~24%) 2

Nicotine (0-34mg/ml3; up to 87mg/ml4)Flavouring (~0.1%) 2

E-cig

Electronic vaping device

Personal vaporiser1

Electronic nicotine delivery system (ENDS)

Vaporette1

Vaping pen1

E-hookah1

“CIG-A-LIKEs”(disposable or pre-

filled cartridges)

“TANKs”(refillable)

16

1. Orellana-Barrios et al. Electronic cigarettes – a narrative review for clinicians. The American Journal of Medicine 2015;128:674-6812. Pellegrino et al. Electronic cigarettes: an evaluation of exposure to chemicals and fine particulate. Ann Ig 2012;24:279-2883. Goniewicz et al. Nicotine content of electronic cigarettes, its release in vapour and its consistency across batches: regulatory implications. Addiction 2014;109:500-5074. Kirschner et al. Nicotine content of liquid for electronic cigarettes. Clin Toxicol 2013;51:6845. Tackett et al. Biochemically verified smoking cessation and vaping beliefs among vape store customers. Addiction 2015;110:868-874

Majority used liquid with nicotine ≤20mg/ml5

VARIOUS TYPES OF E-CIG… STILL EVOLVING!!

17

Modified e-cigarettes• >nicotine in vapour produced by 3rd gen

EC vs1st gen EC1

• 3rd gen EC- higher battery output voltage or sub-ohm vaping1

• Various concentration of formaldehyde1. Pisinger C, Døssing M. Preventive Medicine 2014;69: 248-

260

E-juices: >7700 flavours1

18

Most preferred: Fruity

& candy/n

uts e-liquids2

1. Zhu et al. Four hundred and sixty brands of e-cigarettes and counting: implication for product regulation. Tob Control 2014;23(Suppl 3):iii3-92. Tackett et al. Biochemically verified smoking cessation and vaping beliefs among vape store customers. Addiction 2015;110:868-874

AWARENESS OF E-CIG IN MALAYSIA

54%

73%

40%

79%

62%

66%

19%

0 10 20 30 40 50 60 70 80 90

UK (2010)

USA (2010)

Canada (2010)

Korea (2010)

Malaysia (2011)

Australia (2013)

Netherland (2013)

Awareness

19

Based on International Tobacco Control (ITC) Project1

1. Gravely et al. Int J Environ Res Public Health 2014;11:11691-11704

INCREASE POPULARITY OF VAPING

20

Prevalence of cigarette smoking & e-cigarette use among adults in UK (based on Smoking Toolkit Study)1

1. McNeill et al. E-cigarettes: an evidence update – A report commissioned by Public Health England. 2015. Retrieved from: www.gov.uk/phe

PREVALENCE OF E-CIG USE IN MALAYSIA

10%

15%

4%

12%

19%

20%

19%

4%

6

1%

7%

14%

7%

3%

0 5 10 15 20 25

UK (2010)

USA (2010)

Canada (2010)

Korea (2010)

Malaysia (2011)

Australia (2013)

Netherland (2013)

Current e-cig use Ever-tried e-cig

21

Based on International Tobacco Control (ITC) Project1

1. Gravely et al. Int J Environ Res Public Health 2014;11:11691-11704

Kenapa Vape?

Alasan untuk ‘Vaping’

Sebab utama yang sering di beri:

• Untuk berhenti merokok

• Untuk mengurangkan kemudharatan danrisiko kesihatan ( berbanding dengan rokok

• Untuk mengelak relaps kepada merokok

• Untuk mengurangkan ketagihan, gian dankesan tarikan ( withdrawal symptoms)

1. McNeill et al. E-cigarettes: an evidence update. A report commissioned by Public Health England. Public Health England 2015. Retrieved from: www.gov.uk/phe2. Etter & Bullen. A longitudinal study of electronic cigarette users. Addictive Behaviour 2014;39:491-4943. Czoli et al. Electronic cigarettes in Canada: Prevalence of use and perceptions among youth and young adults. Can J Public Health 2014;105(2):e97-e1024. Farsalinos et al. Characteristics, perceived side effects and benefits of electronic cigarette use: A worldwide survey of more than 19,000 consumers. Int J Environ Res

Public Health 2014;11:4356-4373 5. Harrell et al. Expectancies for cigarettes, E-Cigarettes, and nicotine replacement therapies among E-cigarette users (“Vapers”). Nicotine & Tobacco Research 2014;6. Goniewicz et al. Patterns of electronic cigarette use and user beliefs about their safety and Eenefits: a prospective 6-months pilot study. BMC Public Health

2011;11:786-798

Sebab lain untuk ‘vaping’• Lebih murah• Lebih bebas merokok di tempat awam• Lebih diterima masyarakat• Lebih memuaskan• Rasa lebih sedap• Diguna secara rekreasi ( for fun)• Ingin tahu ( terutamanya remaja yang merokok

dan yg tidak merokok)• Prngruh rakan sebaya• Teknologi ‘vaping’

1. McNeill et al. E-cigarettes: an evidence update. A report commissioned by Public Health England. Public Health England 2015. Retrieved from: www.gov.uk/phe2. Etter. Electronic cigarettes: a survey of users. BMC Public Health 2010;10:231-73. Etter & Bullen. Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy. Addiction Research Report 2011;106:2017-284. Czoli et al. Electronic cigarettes in Canada: Prevalence of use and perceptions among youth and young adults. Can J Public Health 2014;105(2):e97-e1025. Harrell et al. Expectancies for cigarettes, E-Cigarettes, and nicotine replacement therapies among E-cigarette users (“Vapers”). Nicotine & Tobacco Research 2014;6. Tackett et al. Biochemically verified smoking cessation and vaping beliefs among vape store customers. Addiction 2015;110:868-8747. Shiplo et al. E-cigarette use in Canada: prevalence and patterns of use in a regulated market. BMJ Open 2015;5:e007971

Benarkah ianya selamat ?

• ‘Vape’ masih tidak selamat walaupun ianyamengandungi kurang bahan toksik dankarsinogen– Propylene glycol dn glycerine -> formal dehyde bila

dipanaskan ( bahan awet mayat)– Kabus/asap yang terhasil boleh menyebabkan iritasi tekak

dan mata, batuk, sakit kepala, pening dan susah bernapas– Bahan toksik dan karsinogen yang di uji dalam EC hanyalah

untuk apa yang di ketahui ada dalam rokok. Lain lain bahan yang terkandung dan terbentuk bila dipanaskantidak dikaji

– ‘liquid nicotine’ sangat toksik jika di telan

Boleh kah berlaku ketagihan denganmenggunakan vape’ ?

• Di dapati jus yang di katakan tidakmengandungi nikotine tetap mengandunginikotine dalam kandungan yang sedikit dannikotine penyebab ketagihan

• Terdapat ‘vape’ yang di kesan mengandungidadah ganja dan dadah lain

• Tabiat memganag vape dan membawanya kemulut utk hisap pun bukan tabiat yang mudahdi buang

Second hand ‘vapping’ tetap ujud

• Wap / kabus yang dihasilkan masihmengandungi nikotin dan bahan toksik yang lain

Mempunyai kesan negatif kepadakanak kanak dan remaja

Mempunyai kesan negatif kepadakanak kanak dan remaja

• Menjadi satu ‘trend’

• Selalu ingin mencuba-> tidak merokok kepadaperokok

• Menjadi penagih dadah tanpa di sedaridengan jus yang mempunyai campuran dadah

‘Vaping’ boleh menjadi satu hazard

• Peralatan yang d gunakan boleh meletup danmenyebabkan kecederaan

• Menyebabkan toksik dan kematian jika di minum terutama oleh kanak kanak

• Loya, muntah, sakit perut, berpeluh, jantunglaju, tremor, sakit kepala, pening -> lemahotot, lumpuh, susah bernafas, koma dan mati

Nicotine

36

Biological effects1 Irritation & burning sensation in mouth & throatIncreased salivation, nausea, abdominal pain, vomiting, diarrheaVasoconstriction, increased heart rate, increased myocardial contractility

Acute toxicity1 Tremors, prostration, cyanosis, dyspnoea, convulsion, comaRespiratory failure: 30-60mg (adults) & 10mg (children)

Meta analysis on NRT use2

No increase risks of serious adverse events

Long term NRT use3 No increase risks of cancer

NRT use in pregnancy4

Category D medicationSignificantly reduce risks of preterm delivery & low birth weight (compared to smokers)Increase risk for birth defect (but the analysis was not adjusted for other known associated factors)

Animal studies5 Accelerates atherosclerosis, reduces sperm quality, promotes growth of cancer cells, proliferation of endothelial cells

1. Mishra et al. Harmful effects of nicotine. Indian J Med Pediatr Oncol 2015; 36(1): 24-312. Moore et al. Effectiveness and safety of nicotine replacement therapy assisted reduction to stop smoking: systemic review and meta nalysis. BMJ 2009;338:b10243. Murray et al. Does nicotine replacement therapy cause cancer? Evidence from Lung Health Study. Nicotine Tob Res 2009; 11(9): 1076-10824. Forinash et al. Nicotine replacement therapy effect on pregnancy outcomes. Ann Pharmacother 2010; 44(11): 1817-18215. Pisinger & Døssing. A systemic review of health effects on electronic cigarettes. Preventive Medicine 2014; 69:248-260

Harmful contents in E-Cig liquid & ‘vapour’1-3

Chemical compounds Toxic effects

Carbonyls / Aldehydes FormaldehydeAcetyldehydeAcroleinAcetoneO-Methyl benzyldehyde

Cytotoxic, carcinogenic, irritant, pulmonary emphysema, dermatitis

Tobacco-specific nitrosamines

N-nitrosonornicotine (NNN)4-(N-nitrosomethylamino)-1-(3-pyridyl)-1-butanone (NNK)

Carcinogenic

Metals CadmiumNickelLeadChromium

TinSilverAluminiumMercuryArsenic

Carcinogenic, nephrogenic, neurotoxic,haematotoxic

Polycyclic aromatic hydrocarbons

Benzo(a)pyreneBenzo(a)anthracene

Carcinogenic

Volatile organic compounds

Toluene; p,m-Xylene Irritant, neurotoxic

Drugs Amino-tadanafil, Rimonabant, coumarin

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1. Pisinger & Døssing. A systemic review of health effects on electronic cigarettes. Preventive Medicine 2014; 69:248-2602. Cheng T. Chemical evaluation of electronic cigarettes. Tob Control 2014;23:ii11-ii173. Farsalinos & Polosa. Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systemic review. Ther Adv Drug Saf 2014;5(2):67-86

Bolehkah E cig dan vape di guna untukberhenti merokok?

Findings of the Reviews 1-3

• Most studies: main chemicals →low concentration or traces (<<CC)

• Some studies: Certain metals were not detected at all1,2

• Some studies: comparable levels (formaldehyde [1 study]; lead & chromium [1 study]) with CC1

• One study: nickel up to 100x higher than CC & silicatebeads5

– >4000 chemicals in CC → completely absent in E-Cig3

– Most toxicants & carcinogens: Reduced by >90%4

39

1. Pisinger & Døssing. A systemic review of health effects on electronic cigarettes. Preventive Medicine 2014; 69:248-2602. Cheng T. Chemical evaluation of electronic cigarettes. Tob Control 2014;23:ii11-ii173. Farsalinos & Polosa. Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systemic review. Ther Adv Drug Saf

2014;5(2):67-864. Lauterbach &Laugesen. Comparison of toxicant levels in mainstream aerosols generated by Ruyan®electronic nicotine delivery systems (ENDS) and

conventional cigarette products. Toxicologist 2012;126(1)5. Williams et al. Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol. PLoS One

40

9 to 450 times LESS than conventional cigarettes1

1. Lukasz et al. Levels of selected carcinogens and toxicants in vapor from electronic cigarettes. Tob Control 2014;23(2):133-139

>970 times MORE nitrosamines in conventional cigarettes1

41

1. Cheng T. Chemical evaluation of electronic cigarettes. Tob Control 2014;23:ii11-ii17

Toxic emission scores: Comparison between CC and E-Cig1

42

1. Farsalinos & Polosa. Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systemic review. Ther Adv Drug Saf 2014;5(2):67-86

2. Laugesen M. RuyonE-cigarette Bench-top tests. Society for Research on Nicotine and Tobacco (SNRT) Dublin, Poster 5-11. Available at: http://www.healthnz.co.nz/DublinEcigBenchtopHandout.pdf

Data from Laugesen (2009)2

Reviews on chemical contents in E-Cig1-3

• Reviewed ~40 studies:– Analytical methods were varied2

– Authors in 34% of the studies → conflict of interest1

– Focus on specific chemical known from studies on conventional cigarettes (CC) 3

• Levels in liquids & vapour: vary considerably & inconsistent

43

1. Pisinger & Døssing. A systemic review of health effects on electronic cigarettes. Preventive Medicine 2014; 69:248-2602. Cheng T. Chemical evaluation of electronic cigarettes. Tob Control 2014;23:ii11-ii173. Farsalinos & Polosa. Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: a systemic review. Ther Adv Drug Saf

2014;5(2):67-86

E-Cig helps to reduce cigarette consumption

Studies Study design Sample size≥50% reduction P-

valueNicotine EC Comparison

Capponetto et al (2013a)1

RCT: Nicotine EC vs Placebo

EC300 smokers

At 1 year : 14.5%

At 1 year: 12.0%

0.55

Bullen et al (2013) 2

RCT: Nicotine EC vs NRT

Patch657 smokers

At 6 months: 57.0%

At 6 months: 41%

0.0002

Polosa et al (2013) 3

Prospectivecohort study

40 Unmotivated

to quit smokers

At 6 months: 27.5% -

Brose et al (2015) 4

Prospective cohort study

General population –unmotivated

to quit

Daily E-Cig users

None E-Cigusers

0.022At 1 year:

13.9%At 1 year: 5.7%

44

E-Cig users had 1.31x the chance to reduce their cigarette consumption by at least half compared to Non-Users5

1. Caponnetto et al. Efficacy and safety of an eLectronic cigarette (ECLAT) as tobacco Cigarettes Substitute: A prospective 12-month randomized control design study. PLoS ONE 2013;8(6):e663172. Bullen et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet 2013; 382(9905):1629-373. Polosa et al. Effectiveness and toletability of electronic cigarette in real-life: a 24-month prospective observational study. Intern Emerg Med 2013;9:537-464. Brose et al. Is the use of electronic cigarettes while smoking associated with smoking cessation attempts, cessation and reduced cigarette consumption? A survey with 1-year follow-up. Addiction 2015;110:1160-11685. McRobbie et al. Electronic cigarettes for smoking cessation and reduction. Cochrane Database of Systemic Reviews 2014; Issue 12: Art No CD010216

E-Cig helps to quit smokingStudies Study design Sample size

Smoking cessation P-valu

e

RR / ORNicotine EC Comparison

Capponetto et al (2013a)1

RCT: Nicotine EC vs Placebo

EC300 smokers

At 3 months: 14.0%

At 3 months: 4.0%

0.008 -

At 1 year: 11.0% At 1 year: 4.0% 0.04

Bullen et al (2013)2

RCT: Nicotine EC vs NRT Patch

657 smokersAt 6 months:

7.3%At 6 months:

5.8%0.46 1.26

Polosa et al (2013)3

Prospectivecohort study

40 Unmotivated to quit smokers

At 6 months: 12.5%

Etter & Bullen (2014)4

Prospective online study

367 vapers At 1 year: 46%

Brose et al (2015)5

Prospective cohort online

study

1759 General population

Daily E-Cig users

None E-Cig users

0.24 0.62

At 1 year: 8.1% At 1 year: 12.9%

45

E-Cig users had 2.26x the chance to stop smoking for at least 6 months compared to Non-Users6

1. Caponnetto et al. Efficacy and safety of an eLectronic cigarette (ECLAT) as tobacco Cigarettes Substitute: A prospective 12-month randomized control design study. PLoS ONE 2013;8(6):e663172. Bullen et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet 2013; 382(9905):1629-373. Polosa et al. Effectiveness and tolerability of electronic cigarette in real-life: a 24-month prospective observational study. Intern Emerg Med 2013;9:537-464. Etter & Bullen. A longitudinal study of electronic cigarette users. Addictive Behaviors 2014; 39:491-4945. Brose et al. Is the use of electronic cigarettes while smoking associated with smoking cessation attempts, cessation and reduced cigarette consumption? A survey with 1-year follow-up. Addiction

2015;110:1160-11686. McRobbie et al. Electronic cigarettes for smoking cessation and reduction. Cochrane Database of Systemic Reviews 2014; Issue 12: Art No CD010216

Predictors for smoking cessation among vapers

46

1. Grana et al. A Longitudinal analysis of electronic cigarette use and smoking cessation. JAMA Internal Medicine 2014;174(5):812-8132. Hitchman et al. Associations between e-cigarette type, frequency of use, and quitting smoking: Findings from a longitudinal online panel survey inGreat Britain. Nicotine & Tobacco Research 2015; 17(10):1187-11943. Tackett et al. Biochemically verified smoking cessation and vaping beliefs among vape store customers. Addiction 2015;110: 868-874

• Intention to quit1,2

– Motivated to quit in the next 3 months (Contemplation stage) 2

• Lower consumption of cigarettes1

• Experience weaker urges to smoke2

• Tank users (particularly daily users)2,3

• Use non-tobacco & non-menthol flavour juices3

• Longer duration of E-Cig use3

• Higher incomes2

‘Dual users’

• Menggunakan kedua dua vape dan menghisaprokok

• Indicates: nicotine addiction is still significant & experimenting with e-cig

PREVALENCE OF DUAL USERS

Studies Methodology Prevalence

Goniewicz et al (2013)

Online survey in Poland; 179 E-Cig users

- 66% E-Cig only users- 25% dual users (<5cig/day)

Etter & Bullen (2014)

Online survey; 477 E-Cig users (after 1 month), 367 E-Cig users (after 1 year)

- 72% E-Cig only users- 28% dual users

Farsalinos et al (2014)

Online survey; 19,353 E-Cig users

- 81% E-Cig only users- 19% dual users (68.5% daily

smokers)

Harrel et al (2014) Online survey; 1,434 E-Cig users - 79% E-cig only users- 21% dual users

ASH Smoke free GB

Cross-sectional yearly (population) online survey (GB)~12,000 adults

- 40% E-Cig only users- 60% dual users

48

1. Goniewicz et al. Patterns of electronic cigarette use and user beliefs about their safety and Eenefits: a prospective 6-months pilot study. BMC Public Health 2011;11:786-7982. Etter & Bullen. A longitudinal study of electronic cigarette users. Addictive Behaviour 2014;39:491-4943. Farsalinos et al. Characteristics, perceived side effects and benefits of electronic cigarette use: A worldwide survey of more than 19,000 consumers. Int J Environ Res Public Health

2014;11:4356-4373 4. Harrell et al. Expectancies for cigarettes, E-Cigarettes, and nicotine replacement therapies among E-cigarette users (“Vapers”). Nicotine & Tobacco Research 2014;5. McNeill et al. E-cigarettes: an evidence update. A report commissioned by Public Health England. Public Health England 2015. Retrieved from: www.gov.uk/phe

PERBEZAAN

ROKOK BIASA ROKOK ELEKTRONIK

Mengandungi tembakau yang dicarik

dan digulung

Mengandungi cecair nikotin yang

tulen dengan kepekatan sebanyak

4mg/1ml (sumber analisa dari Pusat

Racun Negara)

Kandungan emisi bagi kandungan

nikotin adalah di kawal di bawah

Peraturan-Peraturan Kawalan Hasil

Tembakau 2004

Kandungan emisi tidak di kawal dan

belum ada kajian dibuat setakat ini

untuk melihat tahap emisi tersebut

Mengandungi lebih 4000 bahan kimia

merbahaya

Mengandungi bahan-bahan

karsinogenik yang lain seperti

Formaldehyde dan Logam Berat

(Heavy Metals) yang boleh

menyebabkan kanser

PERBEZAAN

ROKOK BIASA ROKOK ELEKTRONIK

Kesan sampingan jangka panjang

terutama kanser telah terbukti

Kesan sampingan jangka panjang

terutama kanser masih belum dapat

dibuktikan dan masih perlu kajian

lanjut

Sukar untuk diubah suai berikutan

kandungan dalam bentuk pepejal

Mudah untuk diubahsuai berikutan

kandungan dalam bentuk cecair dan

kebarangkalian penggunaan dadah

sintetik adalah tinggi

Risiko keracunan kepada kanak-kanak

adalah rendah disebabkan bentuk

fizikal

Risiko keracunan kanak-kanak adalah

tinggi disebabkan berbentuk cecair ,

berwarna menarik serta bau yang

harum

Rumusan

• Penggunaan EC semakin meningkat• EC mengandungi kurang bahan toksik dan karsinogen berbanding

rokok• Kesan samping akut yang kurang berbanding rokok• Kesan jangka panjang bahan kimia dalam vape terhadap badan

masih tidak di ketahui• Kebanyakan mengguna vape untuk mengurangkan kemudharatan

dan ada yang mengguna vape kerana ingin tahu• Ramai di kalangan yang pernah guna vape tidak terus

menggunakannya• Mungkin boleh digunakan untuk mengurangkan pengambilan rokok

dan berhenti merokok• Terdapat kerisauan jika vape di salah guna untuk pengambilan ganja

dan dadah lain, keracunan dan liquid vape dan tidak di kawal

Prinsip asas dalam berhenti merokok

• Tetapkan tarikh untuk berhenti..

• Kurang kan penggunaan rokok ke kosong padatarikh ‘ quit day’

• Gunakan salah satu NRT/farmakoterapi untuk2-3 bulan

NRT

• Di preskrip oleh pengamal perubatan

• Penggunaannya di pantau

• Datang dalam pelbagai dos

• Tidak datang dalam pakej yang menarik

• Ada dos dan tempoh yang di tentukan

Pengganti rokok..

• Vape untuk ganti rokok dalam usaha berhentimerokok?

– NRT

• Vape untuk ganti rokok sebagai alternatifkepada merokok ?

– Harm Reduction

Fikirkan..

• Jika seorang perokok tegar telah berusahauntuk berhenti merokok menggunakan vapedatang berjumpa doktor…

– Adakah doktor patut menyuruh beliau berhentivape dan kembali menghisap rokok ?

Fikirkan…

• Adakah perokok beralih kepada vape untukberhenti merokok kerana KBM kita gagal ?

Fikirkan …

• Adakah kanser akibat bahan kimia dalam vapelebih kurang bahaya dari pada kanser akibatdari bahan kimia dalam rokok ?

Kesimpulan

• Lebih banyak kajian perlu dijalankan terhadappenggunaan vape dari aspek kesan sampingandan kesesuaian untuk di gunakan sebagaipengganti rokok dalam usha berhenti merokok

• Perlu ada pengawalan

SAY NO TO SMOKING, VAPING AND USING TOBACCO PRODUCT

Health is the greatest wealth

Thank You

Counselling for vapers

Dr Hizlinda Tohid

Department of Family Medicine

Aims of the counselling

• To make them realise that:

– “Total abstinence from smoking or any tobacco product is the best”

– “Vaping is still NOT SAFE even though the harm is lesser than smoking cigarettes”

• To empower motivation and self-efficacy:

– “I want to stop smoking & vaping“

– “I can do this”

EXPLORE ADVICE ASSIST

Explore to determine….

• Gaps in knowledge & misconception– Ideas about smoking & vaping

• Risks if the patient continues smoking cigarettes– Individual health risks– Health risks to family members

• Likelihood for the patient to stop smoking in near future– Readiness to quit smoking– Nicotine dependence– Barriers

• Ability to quit smoking– Confidence– Self-efficacy

WHO’s BRIEF INTERVENTION

Relevance; Risks; Rewards; Roadblocks; Repetition

WHO. Strengthening health systems for treating tobacco dependence in primary care. Part III: Training for primary care providers: Brief tobacco interventions. 2013

5A Approach

5A’s approach

ASK

• Smoking status

ADVICE

• Advice all smokers to quit (clear, strong & personalised)

ASSESS

• Readiness to quit smoking

• Nicotine dependence

ASSIST

• Advice on specific strategies

• Develop quit plan

• Provide self-help materials

• Prescribe medication

ARRANGE FOLLOW-UP

• WHO –one week after the quit attempt

• Refer to quit smoking clinic

ASK ADVICEREFER/

ACTASK

BRIEF ADVICE

CESSATION SUPPORT

ABC approach: New Zealand

AAR or 3A’s approach

5R’s approach

RELAVANCE RISKS REWARDS ROADBLOCKS REPETITION

What has he tried before?

What went wrong?What were the

barriers?

Perceived harmful to continue smoking?

Misperception? Unable to relate with the risks?APPRECIATION OF RISKS &

BENEFITS

DIFFICULTIES TO QUIT

Explore about E-Cig use

Type of E-Cig Identify those > likely to quit smoking (e.g. tank users)

Duration Identify those > likely to quit smoking (e.g. longer duration of use)

Frequency Indicates nicotine addiction

Situations Suggest reasons for vaping & seriousness to quit smoking

Total substitution

Indicates: use to reduce harm or help quitting

Dual usage Indicates: nicotine addiction is still significant & experimenting with e-cig> Likely to discontinue vaping

Explore perception about vaping

Reasons for vaping

Identify those > likely to quit smoking

Benefits of vaping

Positive perception of vaping

Satisfaction with vaping

Most discontinued vaping because it could not satisfy them similarly like smoking

Withdrawalsymptoms

Indicates nicotine obtained from vaping is inadequate to meet nicotine obtained from smoking

Improvement of symptoms

Positive experience of vaping increases chance for total substitution

Worsening of symptoms

Negative experience of vaping decreases chance for total substitution

What advice would you give?

• Provide accurate information

• Correct misconception

Misconception & Gaps

in knowledge

• Clear advice: “Quit smoking is the best thing you can do for your health”

• Clear advice: “Vaping is still NOT SAFE even though the harm is lesser than smoking cigarettes”

• Convince patients to use effective smoking cessation interventions

• State aim of interventions: Stop the use of any tobacco products altogether

High risks if continue smoking

• Many barriers: Discuss possible strategies (problem solving skills)

• Nicotine dependence: Offer pharmacotherapy

• Poor self-efficacy: Behavioural therapy

• Not ready: Guide on proper vaping, aiming for smoking abstinence

Unlikely to stop

smoking in near future

McNeill et al. E-cigarettes: an evidence update. A report commissioned by Public Health England. 2015. Retrieved from: www.gov.uk/phe

WHO. Electronic nicotine delivery system. 2014. Document FCTC/COP/6/10

How to assist?

• Provide pamphlets on smoking cessation

• Reassess & repeat counselling during every follow-ups

• Refer to quit smoking clinics:

– KKM: Quit smoking clinic at Klinik Kesihatan

– UKM: Quit smoking clinic at Pusat Perubatan Primer PPUKM

Quit smoking clinic by the pharmacists