e-cigarettes dan vape pengganti rokok
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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
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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
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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
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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
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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
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