SEMINAR ON TOBACCO

SUBMITTED BY:
Zaiba shareef
4th pharm D
Roll no. 16Q1030
CONTENTS:
Introduction
Definition
Sources
Active Principles
Mode Of Intake
Mechanism
Cinical Symptoms
Health Consequeces Of Tobacco Use.
Nicotine With Drawal
Investigation
Management
INTRODUCTION:
o TOBACCO plant is native to north and south
american continents and they knew its
cultivation 8000 years ago.
o It was christopher columbus who landed in
america in year 1492 who brought this plant to
european countries.
o Portuguese traders brought tobacco plant in
india during 1600 through goa and indians
started cultivating it.
o In india, earlier it was restricted to Royal people
but later in 17th century even common people
started using it.
TOBACCO IN INDIA:
British East India company grew
tobacco in india as cash crop and its
use became widespread whenever
Cultivated
British ruled.tobacco in
India
Exported to
britain

Re-imported cigarettes
to India to earn revenue
TOBACCO:
DEFINITION:

A preparations of nicotine-rich Leaves of an

American plant which are Cured by a process of
drying and fermentation for smoking or chewing .

Tobacco use may be defined as any habitual

use of tobacco plant leaf and its products. The
predominant use of tobacco is by smoke
inhalation of ciggarettes,pipes and cigars.
 Smokeless tobacco refers to a variety of tobacco
products that are either sniffed,sucked or chewed..

Tobacco is one of the most widely

abused substances in the world. It is
highly addictive. The centers for disease
control and prevention estimates that
tobacco
Causes 6 million deaths per year. This
makes tobacco the leading cause of
preventable death.
SMOKELESS TOBACCO:
o Known as spit tobacco, chew,
Snuff and Dip is a form of tobacco
that has become popular, especially
With athletes.
o Chewing on an average-size piece of
Chewing tobacco for 30 minutes can
deliver as much nicotine as smoking
three cigarettes.
SMOKELESS FORM OF TOBACCO USE IN
INDIA:
o Pan(betel quid) with tobacco,
Pan masala with tobacco.

o Tobacco,areca nut and slaked lime

Preparations, manipuri tobacco,
Mawa, khaini, chewing tobacco,
Snus, gutkha.
WORLD TOBACCO FACTS:
o 130 crore people world wide smoke.
o 6,00,000 crore cigarette sticks are smoked
worldwide every year.
o Tobacco kills up to half of its users.
o Tobacco kills nearly 60 lakh people each
year.
o More than 54 lakh of those deaths are the
result of direct tobacco use, while more than
6 lakhs are result of non-smokers being
exposed to second hand smoke.
o Unless urgent action is taken, the annual
death toll could rise to more than one crore
by 2020 and 1.6 crore by 2025.
o Nearly 80% of the world’s 130 crore
smokers live in low- and middle income
countries.
o Tobacco is the second major cause of
death in the world.
o Approximately one person dies every six
seconds and 10 per minute due to tobacco.
Children who are
engaged in
tobacco related
work are
especially
vulnerable to
“green tobacco
sickness”, Which
is caused by the
continous
absorption of
o Smoking kills more people each year than
AIDS, fires, car accidents, murders, suicides,
alcohol and other drugs combined.
o Developed countries have reduced smoking
by 10% while developing countries have
increased by 60% after 1970.
o Tobacco use is linked to a large number of
diseases and is the single most preventable
cause of death in the world, according to the
world health organization.
INDIAN SCENARIO:
o 7,00,000 deaths per year due to smoking

accounting for nearly 2200 deaths every day

and 3 people every 2 min.
o 4 lakh cases of cancer, 13 lakh cases of heart

ailments, 80 to 90% of lung cancer cases due to

smoking.
o Single most preventable cause of premature death.
TOBACCO USE AMONG
YOUTH IN INDIA:
o Tobacco is used by the youth all over india
with a wide range of variation among states.
o Two in every ten boys and one in every ten
girls use a tobacco product.
o Initiation to tobacco products before age
of 15 years is increasing.
o India is the world’s third largest producer of
tobacco (next to china and brazil) and also
the second largest consumer of
unmanufactured tobacco.
SMOKE - A DEADLY
MIXTURE:
o Cigarettes burn at 900 degree celcius to 1000
degree celcius.
o Cigarette smoke contains over 4000 chemicals
and 69 of these are known to cause cancer.
o The smoke contains: Tar, sticky substance that
contains many poisonous chemical such as :
Ammonia (found in floor and window cleaner),
toulene (found in industrial solvents) and
acetone (found in paint stripper and nail polish
remover)
o Nicotine, the addictive drug in tobacco.
Carbon monoxide: a poisonous gas that
reduces the amount of oxygen taken up by a
person’s red blood cells.
Hydrogen cyanide : the poison used in gas
chambers during world war II .
Metals :including lead, nickel, arsenic (white
ant poison) and cadmium (used in car
batteries).
Pesticides : such as methoprene (found in flea
powder). Other chemicals such as Benzene
(found in petrol) and Naphthalene (found in
mothballs) are also in tobacco smoke.
o These chemicals are absorbed into the blood,
reaches every organ system in the body and
are cancer causing, mutagenic and tumor
causing.
o A cigarette contains 8 or 9 milligrams of
Nicotine.
o A cigar contains 100-200mg of Nicotine.
o There is enough Nicotine in 4 or 5 cigarettes
to kill an average adult if ingested whole.
o Tobacco takes 10-25 years to be
discomposed into the land.
NICOTINE:
Nicotine is the main
addictive chemical in
tobacco. It causes a rush
of adrenaline when
absorbed in the
bloodstream or inhaled
via cigarette smoke.
Nicotine also triggers
an increase in
dopamine.This is
sometimes referred to as
the brain’s “happy”
chemical.
o Nicotine is a colourless, toxic alkaloid made
up of carbon , hydrogen and nitrogen.
o The primary reason why nicotine use has
turned into worldwide concern is because of
its ability to induce a state of euphoria
in the brain of the smoker thus leading to
addiction.
o When a person smoke and inhales nicotine,
the active substances are absorbed through
alveoli into the lungs which initiate.
o Chemical reactions in the nerve endings
which increases the heart rate , memory
alertness and reaction time.
o Neurotransmitters called Dopamine
and later endorphins are released in
the brain producing feeling of
pleasure and satisfaction.
o As an addictive drug, nicotine has two
very potent issues – it is a stimulant as
well as depressant.
 SYMPTOMS OF NICOTINE
ADDICTION:

o Tolerance to nicotine with decreased effect and

increasing dose to obtain same effect.
o Withdrawal symptoms after cessation.
o Smoking more than usual.
o Persistent desire to smoke despite efforts to
decrease intake.
o Extensive time spend smoking or purchasing
tobacco.
o Postponing work, social or recreational events in
order to smoke.
o Continuing to smoke despite health hazards.
NICOTINE IS HIGHLY
ADDICTIVE:
o Nicotine release of
serotonin, dopamine,
norepinephrine

o Neuro-adaptation.
SOURCES:
1. Nicotiana attenuata (wild
tobacco)
2. Nicotiana glauca (tree tobacco)
3. Nicotiana longiflora (cultivated
ornamental)
4. Nicotiana rustica
5. Nicotiana tobacum (commercial
tobacco)
6. Nicotiana trigonophylla (desert
ACTIVE PRINCIPLE:

Nicotiana tabacum and N.rustica

contains the following alkoloids:
1. Nicotine
2. Nornicotine
3. Anabasine
4. Anabatine
 MODE OF INTAKE:
o The commonest source of nicotine poisoning (acute
or chronic) results from smoking tobacco in the
form of cigarettes.
o When a cigarette is lit and inhaled , the smoker is
exposed to both gaseous and particulate
matter. Nicotine and tar are part of the particulate
phase of cigarette smoke.
o When a cigarette is smoked, more than half the
nicotine escapes in the sidestream smoke , while a
large fraction remains in the butt and filter , and it is
only 0.5 to 2 mg (average 1mg) of nicotine that
finally is delivered to the smoker.
o After cigarettes, the next common
source of nicotine toxicity results from
smokeless tobacco which is of two kinds
– snuff and chewing tobacco.
o Because smoking is not involved, people
generally believe that snuff is more
socially acceptable and less harmful.
o Snuff is usually available as finely cut
tobacco powder which is packaged dry or
moist. It contains approximately 14mg of
MECHANISM:
Nicotine binds to stereo-specifically to select
acetylcholine receptors (nicotine receptor).These
receptors are present throughout the body,
particularly in autonomic ganglia, adrenal
medulla, central nervous system, spinal cord,
neuromuscular junctions, and chemoreceptors
of carotid and aortic bodies.
In the CNS, the highest concentration of nicotine
receptors is found in limbic system, midbrain
and brainstem.
CLINICAL (TOXIC) SYMPTOMS:
A. Early effects (15min to 1 hour)
GIT: Nausea, salivation, vomiting, abdominal
pain.
CVS: Tachycardia, hypertension.
RS: Tachypnoea, bronchorrhoea
CNS: Agitation, anxiety, sweating,
headache, blurred vision, confusion, vertigo,
tremor , ataxia, muscle fasciculation, convulsions.
Pupils are first constricted, but may dilate later.
B. Delayed effects (after 1 hour)
GIT : Diarrhoea
CVS :Bradycardia, arrhythmias,
hypotension, shock.
RS : Hypoventilation, apnoea.
CNS : Lethargy, weakness,
hyporeflexia, hypotonia, paralysis, coma.
Death may occur, especially in the case
of ingestion of cigarettes
(inadvertently) by children, or exposure to
insecticidal nicotine.
Nicotine dependence is the most widely
preva- lent and deadly of all the substance
 PHYSICAL STATUS
EXAMINATION:

o Physical effects of nicotine use include

increased Heart rate, accelerated blood
pressure and weight loss.
o Physical effets of nicotine withdrawal and
smoking cessation include weight gain due
to increase in appetite, decreased heart
rate , and improvement in senses of taste
and smell.
o Patient commonly discloses the odor of
smoke, tar stained teeth and pre mature skin
MENTAL STATUS
EXAMINATION:
o Nicotine may enhance an individuals
level of alertness.
o Tobacco abuse and dependence may
stimulate a frantic, almost manic picture.
o The speech may also be accelerated in
line with the behaviour.
o Tobacco use can contribute to irritability
often soothened by a dose of nicotine
HEALTH CONSEQUENCES OF
TOBACCO USE:
o Lung cancer.
o Non-pulmonary cancers : Mouth, larynx,
oesophagus, stomach, liver, pancreas,
bladder, uterine cervix, breast, brain.
o Respiratory disease : Emphysema,
bronchitis, asthma, pneumonia.
o Cardiovascular disease : Coronary heart
disease, hypertension, arterial
thrombosis, stroke.
o Obstetric and neonatal conditions : Abortion,
abrubtio placenta praevia, preterm labour,
pre-eclampsia, growth retardation,
congenital malformations , sudden infant
death syndrome, foetal or neonatal
death.
o Other conditions : Peptic ulcer, osteoporosis,

Alzheimer’s disease.
EFFECTS ON MALE FERTIITY
AND ERECTILE DYSFUNCTION:
o Smoking can harm a man’s sexuality
and fertility.
o Erectile dysfunction because it
decreases the amount of blood flowing
into the penis.
o Impairs sperm motility, reduces
sperm lifespan and may cause genetic
changes that can affect a man’s
offspring.
WOMEN WHO SMOKE DURING
PREGNANCY ARE MORE LIKELY TO
HAVE:
o Pre mature baby or LBW
o Am ectopic pregnancy
o Spontaneous abortion or miscarriage
o Vaginal bleeding
o Placental abruption (placenta peels
away, partially or almost completely,
from the uterine wall before delivery)
o A stillbirth
NICOTINE WITHDRAWAL:
Manifestations of nicotine withdrawal can
occur within 4 to 8 hours of the last
cigarette. In fact most chronic smokers
experience some withdrawal symptoms
on waking up each morning.
Manifestation include changes in mood,
insomnia , difficulty concentrating,
restlessness, decreased heart rate
(average decline is 8 beats per minute),
INVESTIGATION:
o Acute poisoning can be confirmed by estimating
plasma nicotine level ; but the short half-life of
nicotine necessitates early withdrawal of blood.
High pressure liquid chromatography is
generally utilised to assay nicotine levels.
Plasma level greater than 40 to 50 ng/ml
indicates serious toxicity.
INVESTIGATION:
o Polymorphonuclear leucocytosis
and glycosuria are often
encountered in nicotine overdose.
o Passive tobacco smoke exposure
is usually determined by
estimating nicotine levels in
plasma, urine, or saliva.
MANAGEMENT:
o Decontamination by stomach wash. Emesis is
contraindicated. Activated charcoal is effective
and must be administered in the usual manner.
o Since nicotine is weakly alkaline, excreation
can be enhanced by acidification of urine.
o Symptomatic and supportive measures :
Benzodiazepines for convulsions, Atropine for
bradycardia, IV fluids and vasopressors
(dopamine or noradrenaline) for hypotension,
respiratory compromise is managed by oxygen,
intubation, positive pressure ventilation .
5 STEPS FOR QUITTING
TOBACCO:

1. Get ready.
2. Get support.
3. Learn new skills and behaviour.
4. Get medication and use it
correctly.
5. Be prepared for relapse.
 5 A’S
Ask : about tobacco use.
Advise : to quit in a clear, strong and
personalised manner.
Assess : willingness and readiness to
quit.
Assist : for quitting.
Arrange : for counseling and
pharmacotherapy.
 5 R’S
RELEVANCE
“Do you think quitting smoking is
an important thing to do for yourself
and others around you?”
RISKS
“ What effect do you think your
continued smoking will have on you
and others around you?”
ROADBLOCKS

“What Is Stopping You From Quitting?”

REWARDS

“ Can you identify the benefits of quitting

for yourself and not smoking around others?”

REPETITION

Repeat interventions until smoker

expresses interest in quitting.
 METHODS TO QUIT NICOTINE
ADDICTION:
1.Nicotine replacement therapy
o Nicotine gum (polacrilex)

o Nicotine transdermal patch system.

o Nicotine nasal spray.

o Nicotine delivery through the oral mucosa.

Common adverse events common to

NRT products include dizziness, nausea and
2.Non – nicotine therapies (medications)
o Bupropion , Glaxosmithkline.
o Varenicline , pfizer.
o Nortriptyline.
o Clonidine .

3.Novel therapies
o Anti – smoking vaccine (Nic VAX)
o Green smoke electronic cigarette.
4.Behavioural treatments.

5.Diet .

6.Activity..

7.Hypnosis..

8.Acupuncture.

9.Motivational therapies.
NICOTINE REPLACEMENT
THERAPY:
Nicotine was the first pharmacological agent
approved by the Food and Drug administration
FDA for use in smoking cessation therapy.
Nicotine replacement therapy (NRT) works
by making it easier to abstain from tobacco
but partially replacing the nicotine previously
obtained from tobacco.
o The Nicotine in tobacco leads to actual

physical dependence. This can cause

unpleasant withdrawal symptoms when a
person tries to quit.
o Nicotine replacement therapy (NRT) gives
you nicotine – in the form of gum, patches,
sprays, inhalers, or lozenges – but not the
other harmful chemicals in tobacco.
o NRT can help relieve some of the physical

withdrawal symptoms so that you can

focus on the 
psychological (emotional) aspects of quitt
ing
..
o Many studies have shown using NRT
can nearly double the chances of quitting
Types of nicotine replacement therapy:
The US Food and Drug Administration
(FDA) has approved 5 forms of nicotine
replacement therapy (NRT):
o Patch.

o Gum.

o Nasal spray.

o Inhalers.

o Lozenges.
Nicotine Patches (Transdermal Nicotine
Systems):
o Patches can be bought with or without a

prescription.
o Patches give a measured dose of

nicotine through the skin. You’re weaned

off nicotine by switching to lower-dose
patches over a course of weeks. Many
o The 16-hour patch works well if you are

a light-to-average smoker. It’s less likely

to cause side effects. But it doesn’t

deliver nicotine during the night, so it

may not be right if you have early

morning withdrawal symptoms.

o The 24-hour patch provides a steady

How to use nicotine patches: 
Depending on body size and smoking
habits, most smokers should start using a
full-strength patch (15-22 mg of nicotine)
daily for 4 weeks, and then use a weaker
patch (5-14 mg of nicotine) for another 4
weeks. The patch is changed every day. It
should be put on in the morning on a clean,
dry area of the skin without much hair. It
 Possible side effects of the nicotine patch include:
o Skin irritation (redness and itching)

o Dizziness

o Racing heartbeat

o Sleep problems or unusual dreams

o Headache

o Nausea

o Muscle aches and stiffness

 Nicotine gum
(nicotine polacrilex):
o Nicotine gum can be bought without a

prescription.
o Nicotine gum is a fast-acting form of

replacement. Nicotine is taken in through

the mucous membrane of the mouth. You
can buy it over the counter (without a
o Another advantage of nicotine gum is that

it allows you to control the nicotine doses.

The gum can be used as needed or on a

fixed schedule during the day.

o The most recent research has shown that

scheduled dosing works better. A schedule

of 1 to 2 pieces per hour is common. On

the other hand, with an as-needed

Possible side effects of nicotine gum include:
o Bad taste
o Throat irritation
o Mouth sores
o Hiccups
o Nausea
o Jaw discomfort
o Racing heartbeat
o Nausea
o The gum can also stick to and damage dentures
and dental work.
Nicotine nasal spray:
o Nicotine nasal spray is only available by

prescription.
o The nasal spray delivers nicotine to the

bloodstream quickly because it’s absorbed

through the nose. It relieves withdrawal
symptoms very quickly and lets you control your
nicotine cravings. Smokers usually like the nasal
spray because it’s easy to use when you need it.
 How to use nicotine nasal spray:
o Most people are told to use 1 to 2 doses per hour. (1

dose = 2 sprays, 1 in each nostril.) At least 8 doses (16

sprays) each day may be needed when you first start,
but use as directed by your health care provider. You
should not use more than 40 doses (80 sprays) per
day. Instructions can vary. Talk to your provider about
the plan that’s best for you.
o The FDA recommends that the spray be prescribed for

3-month periods and that it not be used for longer than

6 months.
Possible side effects of nicotine spray:
The most common side effects of the
spray get better in about 1 to 2 weeks
and can include:
o Nasal irritation
o Runny nose
o Watery eyes
o Sneezing
o Throat irritation
o Coughing
o Other side effects are related to nicotine:
o Racing heart
 Nicotine inhalers:
o Inhalers are available only by prescription.

o The nicotine inhaler is a thin plastic tube

with a nicotine cartridge inside. Unlike other

inhalers, which deliver most of the medicine
to the lungs, the nicotine inhaler delivers
most of the nicotine vapor to the mouth
where it’s absorbed into the bloodstream.
o Nicotine inhalers are the FDA-approved

nicotine replacement method that’s

most like smoking a cigarette, which
some smokers find helpful.
o At this time, inhalers are the most

expensive form of NRT available.

How to use the nicotine oral inhaler:
You puff on the inhaler and the
cartridge sends a pure nicotine vapor
into your mouth. You may use up the
cartridge all at once over about 20
minutes, or puff on it only a few minutes
at a time. The recommended dose is
between 4 and 20 cartridges a day,
Possible side effects of the nicotine inhaler:
oThe most common side effects, especially

when first using the inhaler, include:

oCoughing

oMouth and/or throat irritation

oRunny nose

oUpset stomach
Other side effects are related to
nicotine:
o Racing heart

o Nervousness

o Headache
 Nicotine lozenges:
o Nicotine lozenges can be bought without a

prescription.
o The lozenge is available in 2 strengths: 2 mg and 4

mg. Smokers choose their dose based on how long

after waking up they normally have their first
cigarette. If you smoke your first cigarette within 30
minutes of waking up, use 4 mg nicotine lozenges. If
you smoke your first cigarette more than 30 minutes
after waking up, use 2 mg-nicotine lozenges.
How to use nicotine lozenges:
oThe recommended dose is 1 lozenge every 1 to
2 hours for 6 weeks, then 1 lozenge every 2 to 4
hours for weeks 7 to 9, and finally, 1 lozenge
every 4 to 8 hours for weeks 10 to 12. The
lozenge makers also recommend:
oDo not eat or drink for at least 15 minutes
before using a lozenge or while using a lozenge.
(Some drinks can reduce how well the lozenge
works.)
oDo not use more than 1 lozenge at a time and do
not use one right after another.
o Suck on the lozenge until it is fully dissolved,

about 20 to 30 minutes. Move it from side to side

in your mouth. Do not bite or chew it like a hard
candy, and don’t swallow it. The nicotine absorbs
through the mucous membranes of the mouth.
o Do not use more than 5 lozenges in 6 hours, or

more than 20 lozenges per day.

o Stop using the lozenge after 12 weeks. If you still

feel you need to use the lozenge, talk to your

doctor.
Possible side effects of the nicotine lozenge
include:
o Nausea
o Hiccups
o Sore throat
o Coughing
o Heartburn
o Headache
o Gas
o Trouble sleeping
o Racing heart
 Choosing and using the right nicotine
replacement therapy for you:
No one type of nicotine replacement therapy
(NRT) is any better than another. When choosing
the type of NRT you will use, think about which
method will best fit your lifestyle and pattern of
smoking or using smokeless tobacco. For example,
do you want/need something in your mouth or
something to keep your hands busy? Are you
looking for once-a-day convenience?
 Here are some important points to think

about as you decide:

o Nicotine gums, lozenges, and inhalers are

substitutes you can put into your mouth

that let you control your dosage to help

keep cravings under better control.

o Nicotine gums and lozenges are generally

sugar-free, but if you are diabetic and

o Nicotine nasal spray works very quickly

when you need it.

o Nicotine inhalers allow you to mimic the

use of cigarettes by puffing and holding

the inhaler. It also works very quickly.
o Nicotine patches are convenient and only

have to be put on once a day.

o Both inhalers and nasal sprays require a

doctor’s prescription.
o Some people may not be able to use patches,
inhalers, or nasal sprays because of allergies or
other conditions.
o Nicotine gum may stick to dentures or dental
work making it hard to chew before “parking.”
o Whatever type you use, take your NRT at the
recommended dose, and use it only for as long
as it’s recommended.
o If you use a different dose or stop taking it too
soon, it can’t be expected to work like it should.
If you are a very heavy smoker or a very light
smoker, or a smokeless tobacco user, you may
want to talk with your health care provider
about how to get the NRT dose that best fits
your needs.
Combining the patch and other nicotine replacement
products:
Using the nicotine patch along with shorter-
acting products, like the gum, lozenge, nasal
spray, or inhaler, is another method of NRT. The
idea is to get a steady dose of nicotine with the
patch and then use one of the shorter-acting
products when you have strong cravings. If you’re
thinking about using more than one NRT product,
be sure to talk to your health care provider first.
High-dose nicotine replacement therapy for heavy
smokers:
Another NRT option is to give smokers a higher
dose based on the amount of nicotine that they’ve
been getting from cigarettes. Sometimes this
method requires larger than usual doses of NRT. At
this time, not much is known about this option.
High-dose NRT should be considered only with a
health care provider’s guidance and close
supervision. It may worsen things if you already
have heart disease or other health problems.
 Bupropion (Zyban):
o Bupropion chlorhydrate (or Zyban) was

initially used in the USA as an

antidepressant.
o Although it proved relatively ineffective at

treating depression, it was observed in

1992 that the treatment took away some
patients’ desire to smoke.
o Since then, scientific studies have shown

that this product can be effective in aiding

smoking cessation, although successful
and permanent cessation is also
dependent on other factors.
o In addition, bupropion is a medicine which

can cause side effects, so it can only be

obtained on prescription and when
How does it work?
Smokers develop a dependence on nicotine, a
chemical product contained within tobacco. Nicotine acts
on the nervous system, where it bonds with receptors
and triggers the release of a chemical messenger,
dopamine, which plays a role in the pleasure felt when
smoking. The specific ways in which bupropion functions
are not entirely clear, but we know that it acts via
chemical messages. It is thought that bupropion reduces
the displeasure of smoking cessation by inhibiting the
recapture of neuromediators and compensating for the
dopamine deficit linked to smoking cessation.
Generally speaking, antidepressants can sometimes be useful
in promoting smoking cessation for three reasons (Hughes et
al., 2007):
o Nicotine withdrawal can produce symptoms of
depression or even, in the worst cases, major
depression. Antidepressants prevent these risks.
o The “antidepressant” properties of nicotine are one of
the factors that drive people to carry on smoking.
Because smokers craving nicotine feel depressed when
they are no longer smoking, they start smoking again
to make themselves feel better. An antidepressant,
however, can replace the effect of the nicotine.
o Antidepressants act on the nervous system and on
certain receptors which have a proven link to nicotine
addiction.
o As the first two hypotheses have not

been proven, it would seem that

bupropion produces particular anti-
smoking effects which are
independent from its
“antidepressant” effect.
Advantages:
o Bupropion helps people to quit

smoking because it:

o Reduces the enjoyment of smoking

o Reduces withdrawal symptoms

o Limits weight gain

Side Effects:
o The most frequently observed side effect is

insomnia, reported in 25% to 35% of cases.

o Patients have sometimes reported the following:

dry mouth, agitation, anxiety, irritability,

depression, shakes, headaches, dizziness,
increased heart rate, back pain, abdominal pain,
sickness, constipation, temporary rash, hives and
very occasionally, epileptic fits (risk of 1 in 1000).
 Summary:
o This medicine is for smokers who have a strong

dependence on tobacco and who have made a

decision to quit smoking. It requires medical
monitoring and supervision as well as an
accompanying quit plan.
o In general, bupropion is particularly useful for

smokers who cannot undergo NRT for medical

reasons, who have experienced several failures
with NRT, or who have a history of depression .
o Your doctor will judge which drug is the most suited

to your needs and expectations. Zyban® (bupropion)

is only available on medical prescription.
o Treatment begins 7 to 14 days before your quit date,

giving the substance time to develop its effects.

o In the first 6 days, one 150 mg tablet is to be taken

each morning.
o From the 7th day onwards, 2 tablets are to be taken

daily, 1 first thing in the morning and 1 in the

afternoon (at least 8 hours after the first).
o The treatment lasts 7 to 9 weeks.

o If you experience substantial or lasting

side effects, do not stop taking the

medicine without speaking to your
doctor. The dose can be reduced to 1
tablet per day, which will considerably
reduce the side effects while remaining
nearly as effective for smoking cessation.
o It is possible to combine Zyban® with
Summary of the dosage:
o Day 1 -6 of the treatment:

1 x 150 mg Zyban every morning.

o Day 7 until the end of the treatment (between 7

and 9 weeks):
2 x 150 mg Zyban
(1 in the a.m. and 1 in the p.m.,) at least 8 hours
later.
o Your smoking quit date should fall between day 7

and day 15 of your treatment. 

BRAND NAME:
o BUPREX-SR 150 tab

o BUPRON SR tab

o BUPRON XL tab

o NICOTEX tab

o SMOQUIT-SR TAB

o UNIDEP-SR

o UNIDEP SR-150 tab

o ZYBAN tab
Varenicline (Champix or Chantix):
Varenicline (Champix or Chantix)
is a molecule that aids smoking
cessation by acting on the brain via
nicotine receptors. The effectiveness of
this treatment has been proven, but
long-term cessation is often achieved
through a variety of methods. In this
 How does it work?
o Smokers develop a dependence on nicotine,
a chemical product contained within
tobacco.
o Nicotine acts on the nervous system, where

it binds to receptors and triggers the release

of a chemical messenger, dopamine, which
plays a role in the pleasure felt when
smoking.
o Varenicline can bind to some of these receptors

- nicotine receptors and acetylcholine α4β2

(alpha4beta2).
o When it bonds with these receptors, varenicline

acts in two ways: it acts like nicotine (partial

agonist), which helps to relieve withdrawal
symptoms, and it also acts against nicotine
(antagonist) by taking its place, which allows it
to decrease the pleasurable effects of smoking.
 Advantages:
o Varenicline aids smoking cessation

because it:
o Reduces withdrawal symptoms by

acting on the nervous system in the place

of nicotine
o Decreases the enjoyment of

smoking by reducing the nervous

system’s sensitivity to nicotine
Side effects:
o The most common side effects

(observed in over 10% of patients) are

nausea (desire to vomit), insomnia
(trouble sleeping), abnormal dreams
and headaches.
o Swissmedic warns of the possible appearance

or aggravation of psychiatric symptoms

(modifications in behavior or thoughts, states of
anxiety, psychoses, changes in mood,
aggressive behavior, agitation, depression,
suicidal thoughts or suicidal behavior). In the
vast majority of cases these symptoms do not
appear, but Swissmedic recommends that
patients be supervised by a doctor when taking
this medicine.
 Summary:
o This medicine obtained the right to enter on the

European Market in 2007. In Switzerland and

France, Champix® has been available in
pharmacies since 12 February 2007. In
Belgium, it has been available since 4
December 2006.
o Champix® is designed to help adults over 18 to

quit smoking. The medicine can only be

obtained on medical prescription.
o Champix® should be used by smokers who
are committed to quitting smoking. In
addition, it is recommended that quitters
receive professional support, medical advice
and monitoring, as this considerably
increases the chances of successful
cessation.
o The patient first sets a quit date.
o The administration of Champix® begins 1 or
2 weeks before that date.
o A box of Champix® contains two sorts of
tablets. Tablets containing 0.5 mg varenicline
are white; those containing 1.0 mg are light
blue.
o The initial dosage consists of one 0.5 mg per

day for 3 days, then one 0.5 mg tablet twice a

day for the next four days. After that, the
dosage is one 1 mg tablet twice a day until the
end of the treatment (12 weeks).
o The dosage can be reduced to 0.5 mg twice a
day for patients who cannot tolerate a dosage
of 1 mg twice a day. For patients with serious
kidney problems, the dose of Champix® should
be 1 mg once a day.
o For patients who have succeeded in quitting

smoking after 12 weeks, the doctor may

recommend a complementary treatment
lasting another 12 weeks. Alternatively, he
or she may decide to stop the treatment
gradually.
o The tablets must be swallowed whole with

water.
o Tablets can be taken during or after meals.
Summary of the dosage:
o Day 1 - 3 of the treatment:

1 x 0.5 mg Champix® (white tablet)

once a day
o Day 4 -7 of the treatment:

1 x 0.5 mg Champix® (white tablet)

twice a day
o Your smoking quit date should fall between day 7
and day 15 of your treatment
o Week 2 – 12 of the treatment:

1 x 1 mg Champix® (blue tablet)

twice a day 
 Cytisine (Tabex):
o Cytisine is also known as baptitoxine and

sophorine.
o Cytisine is a tricyclic quinolizidine alkaloid that

binds with high affinity and specificity to nicotine

acetylcholine receptors.
o Cytisine is a plant based alkaloid found in the

seeds of the golden rain tree (cytisus laburnum).

o It works similar to the drug varenicline (chantix).
oThe molecule Cytisine has been used as an anti-

smoking treatment in Eastern Europe for several

decades.
o it has been used medically to help patients with

smoking cessation .
 Mechanism of Action:
o Cytisine is a low efficacy partial agonist of alpha 4 -

beta 2 nicotinic acetylcholine receptors.

o It excites the nicotine-sensitive cholinoreceptors of the

postsynaptic membranes in the vegetative ganglia,

chromaffin cells in the molecular part of the
suprarenal gland and sinocarotid reflexogenic zone,
which results in excitation of the respiratory center,
predominantly through the reflexes, simulation of
adrenaline release by the medullar part of the
suprarenal glands and a rise in the blood pressure.
o After its absorption in the

gastrointestinal tract, cytisine plays the

part of a nicotine-substitute substance
which decreases the period of
interaction between nicotine and the
corresponding receptors. This in turn
leads to a gradual decrease and
Adverse Reactions:
o GI disorders (dyspepsia and nausea).

o headache.
o increased appetite.
o dry mouth.
o nightmares.
o irritability.
Interactions:
The analeptic effect of cytisine decreases
during combined therapy with anti-
tuberculosis drugs (PASA, streptomicin).

Contraindication:
Advanced atherosclerosis, some form of
schizoprenia, pheochromocytome, conditions
connected with severe impairment of
cardiovascular system and malignant
hypertention.
Indication:
It is particularly appropriate for the
treatment of risk groups of smokers
with health problems on the part of the
cardiovascular and respiratory system
as well as smokers professionally
subjected to tension and stress that are
predisposed to seek a “false comfort” in
 Vaporizer:
o Vapes, vaporizers, vape pens, hookah pens,
electronic cigarettes (e-cigarettes or e-cigs),
and e-pipes are some of the many terms
used to describe Electronic Nicotine Delivery
Systems (ENDS).
ENDS are noncombustible  tobacco
products. 
o These products use an “e-liquid” that may

contain nicotine, as well as varying compositions

of flavorings, propylene glycol, vegetable
glycerin, and other ingredients. The liquid is
heated to create an aerosol that the user inhales. 
o ENDS may be manufactured to look like
conventional cigarettes, cigars, or pipes. Some
resemble pens or USB flash drives. Larger
devices, such as tank systems or mods, bear little
or no resemblance to cigarettes.
 Nortriptyline HCL:
o Nortriptyline HCL, the N-

demethylated active metabolite of

amitriptyline, is a dibenzocycloheptene-
derivative tricyclic antidepressant (TCA).

o Nortriptyline is primirily

indicated for the relief of symptoms of

depression.
Dosage:
Initial : 25mg, OD 10-28 days prior to
selected “quit” date, titrate dose
to 75-100 mg/day, continue therapy
for greater than or equal to 12 wk
after “quit” day.
Mode of action:
o Nortriptyline believed to increase the synaptic

concentration of serotinine and norepinephrine

in the central nervous system by inhibition
of their reuptake by the presynaptic neuronal
membrane.
o Inhibits the activity of
histamine,
5-hydroxytryptamine, and acetylcholine.
o It increases the pressor effect of

norepinephrine but blocks the pressor

response of phenethylamine.
o Additional receptor effects have been

found including desensitization of

adenyl cyclase, down regulation of
Beta-adrenergic receptors and regulation
of serotonin receptors.
Adverse Drug Reaction:
o CENTRAL NERVEOUS SYSTEM: Agitation,anxiety,
Confusion,disorientation,hypomania,insomnia,nightma
res
Restlessness,tingling of ectremities,numbness.
o CARDIOVASCULAR: Acute myocardial
infarction,edema
Cardiac arrhythmia,HTN,tachycardia.
o GASTROINTESTINAL: Abdominal cramps,unpleasant
taste,epigastric distress.
o DERMATOLOGIC: Alopecia,pruritis,urticaria,skin rash.
o GENITOURINARY: Impotence,nocturia,urinary
retention
Interaction:
o Nortriptiline may decrease the effects of:

Acetylcholinesterase inhibitors, alpha 1-

agonist, alpha 2-agonist, gastrointestinal agents.
o Nortriptiline may increase the effects of:

Alcohol, alpha /beta agonist,amphetamines,

anticholinergic agents,anti phycotic agents, CNS
depressants, desmopressin,glycopyrrolate.
o Some products that may interact with
this drug include: arbutamine, "
blood thinners" (such as warfarin), 
disulfiram, thyroid supplements,
anticholinergic drugs (such as 
benztropine,  belladonna  alkaloids),
certain drugs for high blood pressure
 (drugs that work in the brain such as 
clonidine, guanabenz).
Contraindiation:
o Hypersensitivity to Nortriptiline and

similar chemical class dibenzazepines.

o Use in the patient during the acute

recovery phase of MI.

o Use of MOA inhibitors intented
to treat psychiatric discorders.
o Taking MAO inhibitors with this 

medication may cause a serious

(possibly fatal) drug interaction. Avoid
taking MAO inhibitors (isocarboxazid, 
linezolid, methylene blue,
moclobemide, phenelzine, 
procarbazine, rasagiline, safinamide,
 Indication:
o This medication is used to treat mental/mood

problems such as depression.

o It may help improve mood and feelings of well-

being, relieve anxiety and tension, and increase

your energy level.
o This medication belongs to a class of medications

 called tricyclic antidepressants.
o It works by affecting the balance of certain natural

chemicals (neurotransmitters) in the brain.

o This medication may increase serotonin and
rarely cause a very serious condition called 
serotonin syndrome/toxicity.
o Get medical help right away if you develop

some of the following symptoms: fast

heartbeat, hallucinations, loss of coordination,
severe dizziness, severe nausea/vomiting/
diarrhea, twitching muscles, unexplained fever,
unusual agitation/restlessness.
o COMMON BRAND(S): Aventyl, Pamelor

GENERIC NAME(S): Nortriptylineis

Novel therapies
Anti smoking vaccine (nic vax):
o NicVAX is an experimental

conjugate vaccine intended to reduce or
eliminate physical dependence to nicotine.
o According to the U.S. National Institute of

Drug Abuse, NicVAX can potentially be used

to inoculate against nicotine addiction.
Green smoke electronic cigarette:
Green smoke e cigarette do not burn
any tobacco but rather when you inhale
from an e cigarette containing
Nicotine, propylene glycol and a scent
that stimulates the flavor of tobacco.
o Cartridges come in five different

percentages of nicotine: 0, 0.6, 1.2,

1.8, and 2.4.
o They are also available in additional

flavors besides mocha—you can order

menthol, three different types of
tobacco flavor, clove, vanilla, or
PHYSIOLOGICAL CHANGES AFTER
A PERSON QUITS SMOKING:
20 MINUTES : Heart rate return to normal.
12 HOURS : Carbon monoxide level in blood
returns to normal .
2 WEEKS TO 3 MONTHS: Heart attack risks
begin to drop and lung function improves.
1 YEAR : Risk of coronary heart disease
is half that of someone who smoke.
10 YEARS : Risk of developing several types of
cancer is decreased.
Motivational therapy:
o Self help books and websites can provide a

no ways to motivate smokers to quit smoking.

o One well known example is calculating the

monetary savings.
o Some people have been able to find the

motivation to quit just by calculating how

much money they will save after they quit.
Conclusion:
Cigarette manufacturers are the only
manufactures of any product anywhere in the
world are allowed to sell something with known
high levels of carcinogens. Overcoming nicotine
dependence is difficult and takes commitment
,support and time. Even longtime smokers can
reverse much of the damage smoking has done
to the body by quitting nicotine dependence
plus taking healthy lifestyle steps.
Quitting the smoke can keep the
glow of life alive.
THANK YOU