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Rawatan,Pemulihan
Penagihan nikotin Oleh:
Dr Izani Uzair bin Zubair Ketua Penolong Pengarah(Perubatan)
Jabatan Kesihatan Negeri Pulau Pinang
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SMOKERS TRAP FOR LIFE
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Individual
active
passive
preference
dependence
experience
regular / irregular
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I want to do something about my smoking
Happy smokers 30%
Dissonant smokers, 70%
I ncreasing dissonance
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Brief Interventions - The 5A
The essential features;
Ask ( tanya )
Advise ( nasihat )
Assess ( nilai )Assist ( bantu )
Arrange ( atur )
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Is smoking anADDICTION ?
Addiction - criteria :
Psychological and physical
dependence
Withdrawal ( gian )
Compulsive drug use
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Is smoking an addiction
A highly controlled or compulsive pattern of
drug use
Psychoactive or mood altering effects,involved in the pattern of drug taking :
mood -altering , anxiety reducing
and stimulating effects.
Drug functioning as a reinforcer to
strengthen behaviour and lead to further
drug ingestion.
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EPIDIOMIOLOGY
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A heterogeneous market including one thi rd of the populat ion
1,1 bn smokers in the world47% men
12% women
Consumption stable
300 m in developed countries
42% men
24% women
Consumption declining
Smoking
MARKET
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3 million deaths per year
If current smoking patterns persist500 million people presently alive
(9% of the worlds population) willbe killed by tobacco
250 million deaths fromchildren who will start
smoking
250 m i l l ion deaths
from exis t ing
smokers
Smok ing is the single largest preventable cause o f death and disease
MARKET
Tobacco causes
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Smoking Statistics (NHMS)
1986 1996
Overall 21.5% 24.8%
Male 40.9% 49.2%
Female 4.1% 3.5%Urban 19.2% 21.7%
Rural 22.7% 28.6%
Malay 23.7% 27.9%
Chinese 17.7% 19.2%
Indian 15.2% 16.2%
Others 32.8% 32.4%
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* Number of smokers Estimates
2000 2025
Population 22 m 30 m
Population ( < 15 years) 7.5m (34%) 7.2m (24%)
Population ( > 15 years) 14.5m (66%) 22.8m (76%)Prev. adult smokers :
Male smokers 49% 30%
Female smokers 4% 10%Overall adult prev. 25% 20%
Number of adult smokers 3.6 m 4.6 m
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Youth smoking statistics
People age 18 years and < Prevalence
1996 - 16.9%
(male : 30.7%, female : 4.8%)1999 - 18.2%
(males : 29%, females : 8%)
Daily, 45 - 50 youths start to take upsmoking
SURVEY IN SCHOOLS MALAYSIA
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SURVEY IN SCHOOLS MALAYSIA
GLOBAL YOUTH TOBACCO SURVEY 2003
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5 principal causes of all medically
certified deaths(Govt. Hosp.1998)
1. Heart diseases & diseases of
pulmonary circulation
14.09%
2. Septicaemia
12.54%
3. External causes 9.67%4. Cerebrovascular diseases
9.36%
5. Malignant Neoplasm
8.91%
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HEART DISEASES
More than 100 000 people suffer as a result of heart conditions
in year 1998 with more than 12,000 deaths ( inclusive of privatehospital )
Total Admission and Death of Heart
Conditions CVD in Govt Hospital Malaysia
(1988 - 1998)
0
20,000
40,000
60,000
80,000
100,000
120,000
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
Admission Deaths
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Withdrawal symptoms
Psychic
Craving/missingcigarettes
Dysphoria
Difficulties inconcentrating
Irritability, anger,
aggressiveness
Drowsiness,tiredness,sleepiness
Nervousness,tenseness, anxiety
Vivid dreaming
Sociability
Restlessness
ImpatienceInsomnia
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Withdrawal symptomsSomatic
Sweating
Dizziness
Blisters/ulcersmouth and throat
Obstipation
Swelling of jointsand pain
Creeping sensationsin or beneath theskin
Tremor
Hunger/weight gain
Disturbed vision
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Broader useI want to cope when not
allowed to smoke
I want to cut down
I want to quit completely
STRATEGIES
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STRATEGIES
TOTALABSTINENCE
QUIT
relapse
prevention
Cessation
+Motivation
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TOTAL
ABSTINENCE
relapse
prevention
Cessation
Reduction
+
CUT DOWN
completereduction
partial
reduction
Motivation
QUIT
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CONTROLCRAVINGS
TOTALABSTINENCE
QUIT
relapse
prevention
CUT DOWN
completereduction
partial
reduction
partial
reduction
controlledsmoking
Temporary
abstinence
Cessation
Reduction
+Motivation
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Individuality
active
passive
preference
dependence
experience
regular / irregular
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REGISTRATION
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REGISTRATION
REGISTRATION CARD
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REGISTRATION CARD
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BODY MASS INDEX
Weight & Height
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ASSESSEMENT & CREATING INTEREST
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WHEN SMOKERS QUIT..Within 20 minutes of smoking that last cigarette,
the body begins a series of changes
AT 20 MINUTES AFTER QUITTINGBlood pressure decreasesPulse rate drops
Body temperature of hands and feet increases AT 8 HOURS
CO level in blood drops to normalO2 level in blood increases to normal
AT 24 HOURSChance of a heart attack decreases
AT 48 HOURSAbility to smell and taste is enhanced, nerve endings
start
growing
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New clue to why smokers look older
ASSOCIATED PRESS
March 22
Theres a new wrinkle in the old question
of why smokers faces are prematurelylined. A report in The Lancet medicaljournal this week suggests smoking
switches on a gene involved indestroying collagen, the structuralprotein that gives skin its elasticity.
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ARSENIC
Arsenic boleh menyebabkan bibir
anda terbakar dan menyebabkan
nafas anda berbau busuk.
BENZOPYRENE
Bahan ini terdapat di dalam asap
rokok dan merupakan satu bahan kimia
yang boleh menyebabkan kanser.
METHOPRENE
Bahan kimia ini digunakan di dalam
kebanyakan racun serangga khususnya
kntuk menghapuskan kutu.
ACETONE
Bahan kimia ini digunakan sebagai
bahan utama untuk membuat
penanggal pewarna kuku.
LEADKeracunan atau pendedahan kepada Lead dalam
satu tempoh masa yang panjang boleh
menyebabkan tumbesaran terbantut. Ia juga
boleh menyebabkan kerosakan otak.
FORMAL DEHYDE
Bahan kimia ini boleh menyebabkan kanser,
merosakkan paru-paru, kulit dan sistem
penghadaman. Ianya seringkali digunakan untuk
mengawet mayat.
CADMIUM
Bahan kimia ini boleh menyebabkan
kerosakan ginjal, hati dan otak
PROPYLENE GLYCOL
Bahan ini udahkan nikotin menyerap kedalam
sistem tubuh khususnya ke otak.
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Role of Nicotine
ACTION
Release ofanepinephrine from
adrenal cortex
Fuses with
acetylcholinen in the
brain
Release of dopamine
EFFECT
causes fatique &excitement due to
excessive release ofglucose.
Effect on mood,alertness
Pleasure sensation
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SHORTNESS OF BREATH
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SVCObstruction
Lung Cancer
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Mouth cancer
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Emphysema
Bronchietasis
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Chronic Obstructive Airways Disease
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Peripheral
Vascular
Disease
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Women 'suffer more
from smoking'November 15, 2000Web posted at: 6:13 AM EST (1113 GMT)
LONDON, England --Women suffer more from
smoking than men because oftheir generally smaller lungs,scientists say.Women are more vulnerablethan men to the breathingproblems and other harmfuleffects of smoking, Norwegiandoctors found during two yearsof study.
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BREAST CANCER
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CANCER CERVIKS
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abortion
INFANT
cacat
Female smokers has
risk of 3X forabortion duringpregnancy
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PREMATUREDELIVERY
LOW BIRTHWEIGHT
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EXAMINATIONS - PHYSICAL& GENERAL IX
TEST
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LUNG FUNCTION TEST
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LUNG FUNCTION TEST
PULMONARY EXPIRATORY FLOW RATE
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PULMONARY EXPIRATORY FLOW RATE
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FAGERSTROM TEST
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How soon after you wake up do you
smoke your first cigarette?
Do you find it difficult to refrain from
smoking in places where it is
forbidden e.g. in church, at the library,
in cinema, etc.?
Which cigarette would you hate mostto give up?
How many cigarettes do you smoke
per day?
Do you smoke more frequently during
the first hours after waking thanduring the rest of the day?
Do you smoke if you are so ill that you
are in bed most of the day?
1.
2.
3.
4.
5.
6.
Within 5 minutes
6-30 minutes
31-60 minutes
After 60 minutes
Yes
No
The first one in the morning?
All others?
10 or less
11-20
21-30
31 or more
Yes
No
Yes
No
3
2
1
0
1
0
1
0
0
1
2
3
1
0
1
0
Fagerstrms test for nicotine dependenceQuestions: Answers: (mark your alternative)
Minimum score 0Maximum score 10Average score 4
Total
EXAM OF PUPILS
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EXAM OF PUPILS
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EXAM OF FLEXORS
EXAM OF FOOT
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EXAM OF FOOT
BURGERS DISEASE
Chest Xray : COAD
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MRI
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Smoker Non-smoker
C11-Nicotine
MRI
BLOOD PRESSURE
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BLOOD PRESSURE
DENTAL EXAMINATION FOR
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DENTAL EXAMINATION FOR
NICOTINE
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FITNESS TEST
FITNESS TEST (STAMINA)
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FITNESS TEST (STAMINA)
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SMOKING SUE
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SMOKING SUE
GENERAL INFORMATIONSPECIFIC TOWARDS SELF &
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SPECIFIC TOWARDS SELF &
WIFE AND CHILDREN
RISK MALES VS FEMALES
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RISK MALES VS FEMALES
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MESEJ HATI
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MESEJ HATI
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SAVINGS
Expenditure daily
2 box of cig RM 8.00
Nicorette (2mg) 5 tab 0.56 X 5 2.80 Nicorette (4mg) 5 tab 0.68 X 5 3.40
(SAVE RM 150.00 a MONTH
RM 1800.00 YEAR
RM 18,000.00 10 YEARS
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Nicotine Replacement Therapy
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Nicotine Replacement Therapy
AS STIPULATED IN CLINICAL
PRACTICE GUIDELINES OF
MALAYSIA
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Benefi ts Toxici t iesNicot ine
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Fig.7. Benefits and toxicities of (-)-nicotine
Nicotine
Cognitive
EnhancementHypothermia
Vigilance/Antipsychotic
Gastrointestinaldistress
AnalgesiaRespiratory
Paralysis
Anxiolysis Emesis
Neuroprotectio
n
Seizures
Cerebro-vasodilation
Hypertension
Benefi ts Toxici t iesNicot ine
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Rawatan
farmakologikal
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Nico t ine rep lacment therapy
NRT GUM (Nico rette Gum )
Flexible dosing to meet individual and
situational needs
Two strengths: 2mg for low- and medium-
and 4mg for high-dependent smokers
Some behavioral replacement (oral
gratification)
Good for relapse prevention
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Dosage Guide
Allow the smoker to control how much nicotineis used, and when it is used.
Nicorette comes in different strengths so it is
important to prescribe the correct strength tosuit the persons individual smoking pattern.
ALWAYS ENCOURAGE FIRST TI ME USER TO CHEW ONE
PIECE OF THE NICORETTE GUM IN FRONT OF YOU TOENSURE THE RIGHT CHEWING TECHNIQUE IS USED.
D G id
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Dosage Guide
Most people use 10-15 pieces of Nicorettegums a day.
However, they should not chew more
than 60mg (30 pieces of 2mg or 15 pieces
of 4mg) in a day Nicorette should be used
for at least 3 months before gradually
reducing the number of pieces chewed.
ALWAYS ENCOURAGE FIRST TI ME USER TO CHEW ONEPIECE OF THE NICORETTE GUM IN FRONT OF YOU TO
ENSURE THE RIGHT CHEWING TECHNIQUE IS USED.
Dosage Guide
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The level of nicotine dependence based on Fagerstrom Nicotine
Dependence Questionnaire (FNDQ)
Nicorette 4mg -for heavy, highly dependent smokers
(e.g. smoke more than 25 or more cigarettes a day
& FNDQ score 6 & above)
Nicorette 2mg -for occasional and regular smokers of less than
10 cigarettes or irregular smokers of 10-25
cigarettes a day & FNDQ score below 6.
ALWAYS ENCOURAGE FI RST TI ME USER TO CHEW ONE
PIECE OF THE NICORETTE GUM IN FRONT OF YOU TO
ENSURE THE RIGHT CHEWING TECHNIQUE IS USED.
Dosage Guide
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Dosage Guide
Nicorette gum is not an ordinary gum and should
not be chewed in the ordinary way.
To make sure the user get the most from their gum,
they should follow the special Nicorette chewing technique:
(Chew Rest Chew Technique)
CHEW Chew Nicorette Gum slowly until taste becomes strong.
REST Rests Nicorette Gum between the gum and cheek.
CHEW Chew Nicorette Gum again once the taste has faded
The process is repeated for approximately 20-30mins.
ALWAYS ENCOURAGE F IRST TIME USER TO CHEW ONE
PIECE OF THE N ICORETTE GUM IN FRONT OF YOU TO
ENSURE THE RIGHT CHEWING TECHNI QUE IS USED.
(Chew Rest Chew Technique)
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(Chew Rest Chew Technique)
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(Chew Rest Chew Technique)
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( q )
CHEWChew Nicorette Gum slowly
until
taste becomes strong.
(Chew Rest Chew Technique)
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REST
Rests Nicorette Gum
between the gum and
cheek.
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(Chew Rest Chew Technique)
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(Chew Rest Chew Technique)
CHEWChew Nicorette Gum again
once the taste has faded
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Park it.(slow down if
you start feeling
uncomfortable)
(Chew Rest Chew Technique)
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After about 1 hour- safely discard it
(Chew Rest Chew Technique)
Treatment is divided into two phases:Phase One
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- Help smokers to overcome the psychological
dependence on Nicotine- Duration of treatment is 3 months.
- Smokers are advice to use a fixed amount of Nicorette
gums
e.g. 8-10 pieces a day for 3 months.
Phase Two
- Help smokers to overcome the physical
dependence on Nicotine.- Duration of treatment is 4-6 weeks.
- Smokers are advice to reduce the intake of
Nicorette gum gradually.
e.g. reduce one piece each week.
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Penampal NRT
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p
Dipakai sepanjang hari semasaterjaga.
Rawatan sekali dalam sehari.
Didapati dlm 3 jenis dos-5mg,10mgdan 15 mg
Sesuai untuk tahap nikotin dari tahap
sederhana hingga tinggi Mulakan dengan menampal 15mg dan
seterusnya ke dos yang lebih rendah.
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Nico rette Inhaler
Combines nicotine and behavioral
replacement
Flexible dosing to meet individual andsituational needs
Good for relapse prevention
Ni tt I h l
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Nicorette InhalerCharacteristics Unique NRT form that provides nico t ine
saturated in air via oral inhalat ion
As air is inhaled, it is saturated w ithvapor ised nicot ine
Amount of nico t ine released depends on thevo lume of air pass ing through the nico t ineimpregnated-plug and the temperature
One inhalation del ivers 13mg at RT, 10inhalat ion = 1 puff on a cigarette
The only dosage form to add ress the phys icalas wel l as the behaviou ral dependency
Nicorette Inhaler
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Nicorette InhalerPharmacokinetics
Absorption occurs mainly via the buccal mucosa for
shallow puffing and pulmonary mode for deep inhalation
Nicotine release not affected by the inhalation technique;
comparable Css
T < 15oC - nicotine evaporates more slowly and need to
inhale more frequently
Inhaler use represents 35% nicotine substitution (within
recommended range for replacement therapy)
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Nicorette InhalerDosage and administration The nicot ine vapour can be inhaled ad l ib i tum
either by deep inhalat ion o r by shallow
puf f ing Each 10 mg cartr idge provides up to 5 mg of
nicot ine, released over 20 m ins of act ive &
con t inuou s puf f ing
8-2-2 ru le
6-12 catridges for 8 weeks, then
3-6 catridges for 2 weeks, then
1-3 catridges for 2 weeks
Ni tt I h l
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Nicorette Inhaler
Safety
No serious system ic AE
Most common : headache, heartburn ,nausea, mou th and throat irr i tat ion
Ni t i i t i f f t
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Keeps the weight under control
Controls alertness
Controls feelings
Enhance cognitive functionEnhance mobility
Can provoke euphoria
Decrease smoking cravingsBlocks or decreases abstinence
Nico t ine; posi t ive effects
DIETITIAN
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DIETITIAN
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STRESS MANAGEMENTOCCUPATIONAL THERAPIST
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OCCUPATIONAL THERAPIST
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QUALITY INDICATORSCRITERIA QUIT
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CRITERIA QUIT
1. URINE TEST NEGATIVE2. QUIT 6 MONTHS
3. NON DEPENDENCE NRT
REWARDS
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Blood Screening(4th week)
ECG(6th week)
CX Ray(8th week)
Scaling & Peridontal Rx
(Quit)
Medical Examination
(quit)
REWARDS
*ACHIEVEMENTS QUIT
1998 2003(A )
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1998 -2003(Aug)
22%
33%
43%
50%53% 53%
0%
10%
20%
30%
40%
50%
60%
QUIT(%)
1998 1999 2000 2001 2002 2003(Aug)
*
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0
50
100
150
200
250
1998 1999 2000 2001 2002 2003
malay
indian
chinese
*
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98%
2%
0%
20%
40%
60%
80%
100%
MALE FEMALE
*
-
7/28/2019 rawatan nikotine
145/161
0%
10%
20%
30%
40%
50%
60%
61
40
-
7/28/2019 rawatan nikotine
146/161
-
7/28/2019 rawatan nikotine
147/161
THOSE WHO
QUITAND SMOKE
AGAIN
-
7/28/2019 rawatan nikotine
148/161
-
7/28/2019 rawatan nikotine
149/161
-
7/28/2019 rawatan nikotine
150/161
-
7/28/2019 rawatan nikotine
151/161
-
7/28/2019 rawatan nikotine
152/161
-
7/28/2019 rawatan nikotine
153/161
-
7/28/2019 rawatan nikotine
154/161
FINAL TAKEAWAY MESSAGE
ARTICLES IN LOCAL PAPERS
-
7/28/2019 rawatan nikotine
155/161
-
7/28/2019 rawatan nikotine
156/161
-
7/28/2019 rawatan nikotine
157/161
-
7/28/2019 rawatan nikotine
158/161
-
7/28/2019 rawatan nikotine
159/161
-
7/28/2019 rawatan nikotine
160/161
A smoke freeworld
-
7/28/2019 rawatan nikotine
161/161
TERIMA KASIHTHANK YOU