CLINICAL PRACTICE GUIDELINES ON TREATMENT OF TOBACCO USE AND DEPENDENCE 2003

FLOW CHART OF CLINICAL PRACTICE GUIDELINES ON MANAGEMENT OF TOBACCO USE AND DEPENDENCE

General Population Patients present to a health care setting

Relapse

Ask- screen For Tobacco use

AdviceTo Quit
Current users

Assess Willingness to quit

Yes No

Assist quitting

Arrange follow-up

Non users

Abstinent

Promote motivation to quit

Ex users Patient now willing to quit

Advise on smoking hazards

Relapse Prevention

Patients still unwilling to quit

CONTENTS
Page
FOREWORD EXECUTIVE SUMMARY CORETEAM MEMBERS . LISTS OF ABBREVIATION LISTS OF TABLES ..

ii iv vi vii vii 1 2 2 3 4 4 4 5 8 14 15 17 19 19 20 21 22 23 23 24 25 32 33 36 39

1.

INTRODUCTION Objective ...

2.

GUIDELINE DEVELOPMENT METHODOLOGY Level of Evidence Scale .

3. 4.

ASSESSMENT OF TOBACCO USE . PATIENT WILLING TO QUIT 4.1 Brief clinical intervention . 4.1.1 4.1.2 4.2 Non-pharmacological Intervention . Pharmacological Intervention

Intensive clinical intervention

5. 6. 7.

PATIENT UNWILLING TO QUIT PATIENT WHO HAS RECENTLY QUIT SPECIAL POPULATIONS

7.1 Female smokers Pregnant Women 7.2 Hospitalised smokers 7.3 Psychiatric patients. 7.4 Children and adolescents 7.5 Elderly 8. 9. MANAGEMENT OF WEIGHT GAIN REFERENCES

ALGORITHM GLOSSARY APPENDIX LIST OF CONTRIBUTORS

CLINICAL PRACTICE GUIDELINES ON TREATMENT OF TOBACCO USE AND DEPENDENCE 2002

FOREWORD

Smoking accounts for one out of every five deaths in Malaysia. It is the most important modifiable cause of premature death, responsible annually for an estimated 120,000 years of potential life lost. About 10,000 Malaysia die each year as a result of smoking. Since early studies in the 1950s and 1960s, a large body of epidemiological evidence has accumulated regarding the health effects of smoking. Major cohort studies, many case-control studies, and other data sources provide consistent, convincing evidence linking the use of tobacco with a variety of serious pulmonary, cardiovascular, and neoplastic diseases. A number of consistent findings from this body of evidence are well established.

Tobacco consumption had markedly reduced in most high-income countries. In the United States of America for instance, by 1997 the prevalence of smoking among Americans had dropped to 23% from 40% in 1964. In contrast, however, tobacco consumption in recent years has been rising in developing countries including Malaysia. The prevalence of smoking among Malaysian adults aged 15 years and above had increased from 21% in 1985 to 31% in 2000. Some 49% of all adult males and 5% of all adult females are now current smokers. Due largely to population increase, the number of smokers will continue to rise. Today there are about 5 million smokers in Malaysia, each consuming an average of 14 cigarettes per day. Of these smokers aged 15 years and above 90% are male. Half of these smokers alive today will eventually be killed by tobacco, and the number of annual deaths attributable to smoking will be triple over the next three decade from 10,000 in 1998 to 30,000 by the year 2030.

Nonetheless, as a result of our intensive anti smoking activities since 1991 in conjunction with our National Healthy Life Style Campaign, the level of awareness with regard to the hazard of smoking among the general public both smokers and non smokers alike have markedly increased. Among the current smokers, about 43% of them have attempted to quit on their own, but unfortunately most of them had been unsuccessful.

ii

We know now that smoking is seriously difficult habit to break, and very few smokers succeed in their attempts to quit. Outside of individual strengths and willpower, various countries have proven that healthcare professionals can play an active role in helping smokers to break free of their tobacco addiction through a properly organized smoking cessation programs. Studies have found that a few minutes of firm advice from the doctor, supported by educational materials and the mutual understanding that there would be follow up, gave a 5% quit smoking rate which translated to about 25 exsmokers per year per doctor. Other studies have shown that the greater the intensity of invention coupled with appropriate pharmacotherapy, the higher the success of smoking cessation.

Health Ministry recognized the need for doctors and other health professionals to participate in smoking cessation program. This Clinical Practice Guideline is timely produced to assist doctors and other health professionals to help smokers to quit smoking for good.

(TAN SRI DATU DR. HJ. MOHD. TAHA BIN ARIF) Director General of Health Ministry of Health Malaysia

iii

EXECUTIVE SUMMARY

Tobacco use is recognized as the main cause of premature and preventable death in our country. It is estimated that 10,000 deaths in Malaysia are attributed to smoking yearly. Tobacco dependency does not only cause physical withdrawal, it also causes life long addiction. Hence, due recognition should be given to it as a chronic disease. Malaysia has a high prevalence of smokers especially among the males and adolescents. However despite the high prevalence of tobacco use, healthcare providers are not well trained to manage this problem effectively. Furthermore health care providers lack the knowledge and awareness that treating tobacco dependence is more cost effective as compared to treating tobacco related diseases.

There is no clinical practice guideline available on treatment of tobacco use and dependence in Malaysia. Therefore it is imperative that the Ministry of Health produces a clinical practice guideline (CPG) which is for both public and private health care providers and best suited for Malaysians. With this in mind, the Division of Disease Control initiated and coordinated the preparation of this manual, enlisting the help of experts from the various medical fields relevant to tobacco cessation. This group collaborated for a year, going through the various local and international resources to produce this CPG. This includes the review of national statistics, The US Department of Health and Human Services, Public Health Service CPG on Treating Tobacco Use and Dependence, The Cochrane Collaboration and the New Zealand Smoking Cessation Guidelines. The preliminary draft of CPG was reviewed at a national level conference by independent experts and end-users.

The objective of this CPG is to provide the latest and updated treatment protocols to assist health care providers in managing tobacco use and dependence effectively.

This guideline is based on a combination of two methods, namely adaptation from the three leading and prominent CPGs on tobacco cessation in addition to the latest literature review based on a systematic search for evidence. All recommendations in this CPG are graded based on the appropriate level of evidence and are specific and unambiguous. The health benefits, adverse effects and risks of all recommended pharmacological agents are detailed in table forms. The overall treatment guideline is

iv

provided in a clinical pathway format. Furthermore, the effectiveness and health benefits that are derived from each recommendation in this CPG are taken into consideration.

It is hoped that clinicians and other allied healthcare providers can adopt this evidence based guideline to maximize the success rate of tobacco cessation. However, this CPG is not meant as a substitute for clinical judgement and clinicians are recommended to individualize their treatment strategies.

This CPG is planned for a review at every two-year interval by the committee and appropriately updated if the need arises.

Evaluation of this CPG would include an assessment of the number of smoking cessation services and the outcome of smokers treated throughout Malaysia. Studies to look at improvement in standard of practice regarding smoking cessation treatment will also be conducted.

During the development of this CPG it was realized that there was a lack of local data on tobacco use and dependence. Thus it is recommended that more research be conducted on a national level.

CORETEAM MEMBERS

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

Dr. Hjh Aziah bt. Mahayiddin (Co-Chair) Dr. Mahmud Mazlan (Co-Chair) Dr. Sallehudin Abu Bakar Mr. Wong Kok Thong Dr. Mohamad Haniki Nik Mohamed

Senior Consultant Chest Physician, Ministry of Health Consultant Psychiatrist & Addiction Specialist, Ministry of Health Public Health Specialist, Ministry of Health Chief Pharmacist, Ministry of Health Clinical Pharmacist & Lecturer, University of Science Malaysia

Dr. Mohd Fozi Kamarudin Dr. M. Sheila Dr. Nik Ahmad Nik Abdullah Dr. Noor Zurani Haris Robson

Family Medicine Specialist, Ministry of Health Paediatrician, Ministry of Health Obstetric and Gynaecologist, Ministry of Health Family Medicine Specialist & Lecturer, University of Malaya

Dr. Tengku M. Izam Dr. Mohd. Rizal Hj. Manap

Otolaryngologist, Ministry of Health Public Health Specialist & Lecturer, National University of Malaysia

Dr. Mohamad Ismail Abdul Samad Dr. Anis Salwa Kamarudin (Secretariat) Dr. Zarihah Mohd. Zain (Main Co-ordinator)

Epidemiologist, Ministry of Health Public Health Specialist, Ministry of Health

Epidemiologist, Ministry of Health

Secretariat

1 2 3.

Mr. Mohd. Ishak Jaidin Mr. Harun Masdar Mr. Zakaria Othman

Health Department, Ministry of Health Health Department, Ministry of Health Health Department, Ministry of Health

vi

LIST OF ABBREVIATION

1. CDC 2. CPG 3. CTPR 4. ETS 5. FDA 6. MAO 7. NRT 8. SR 9. TTS

Centres for Disease Control and Prevention Clinical practice guideline Control of tobacco products and regulations Environmental tobacco smoke Food and Drug Administration Monoamine oxidase Nicotine replacement therapy Sustained release Transdermal therapeutics system

LIST OF TABLES

1. The 5 As for brief intervention 2. Clinical use of nicotine gum 3. Clinical use of nicotine patch 4. Clinical use of nicotine inhaler 5. Clinical use of bupropion SR 6. The 5 Rs for enhancing motivation to quit tobacco 7. Problem-related interventions to maintain smoking cessation 8. The 5 As for brief intervention 9. Clinical use of nicotine gum

vii

1. INTRODUCTION
Tobacco cessation strategy is a significant component of an overall tobacco control program to reduce morbidity and mortality due to tobacco-related diseases (CDC, 1984). Unfortunately quitting smoking is not easy. So many smokers have undergone the dilemma of wishing to quit and then been unsuccessful (CDC, 1990-1991; Hatziandreu et al., 1990). Therefore it seems obvious that there must be more to smoking than just a bad habit.

Today enough scientific evidence has been gathered to explain why some smokers had such difficulties with quitting. No matter how intellectually astute a smoker may be, no amount of rationalization will be able to curtail their craving for cigarette.

It is an accepted fact that cigarette smoking is an addiction. Within a few years of daily smoking, most smokers will become dependent, both physically and psychologically. This dependence is due to the neurobiological effects of nicotine on the brain. Nicotine receptors are found in the region of the brain involved in reward and emotion and in those areas associated with learning and memory, namely the hippocampus (Piccittio, 1998). The existence of these nicotine receptors which are directly connected to the reward system in the brain provides physical evidence of how nicotine found in tobacco exerts its addictive effects.

Most smokers attempt to quit at some point in their smoking lives and almost all fail on their first unaided attempt. The chance of success in a single unaided quit attempt is in the region of 1 in 100, and 98% of them relapsed within a period of 12 months (Fiore et al., 1995). It is not uncommon to see smokers who stopped for quite a while but slipped back into smoking and then quit again and then slipped back again, and the cycle continues. Research suggest that people who smoke go through a five stage tobacco addiction cycle that leads them from being non-smokers to new smokers, then to committed smokers, to smokers trying to stop and to finally reformed smokers (Prochaska & Goldstein, 1991). However only a few stay in that final stage. In reality the tendency is for recent or renewed quitters to relapse into nicotine addiction, and the overall cycle.

If smokers can be persuaded to not only quit smoking but also more importantly to stay clean of their addiction, they can benefit their own health and finance, as well as ease the burden on the society that must shoulder their healthcare costs.

We have now sufficient evidence-based treatment modalities that are both efficacious and effective ranging from behavioural therapy to pharmacotherapy. Several cost-

effectiveness analyses have shown that cessation treatments compare quite favourably with routine medical interventions such as the treatment of hypertension and hypercholesterolemia, and with other preventive interventions such as periodic mammography (Eddy, 1986; Health and Human Service, 1991; Tengs et al., 1995; Lightwood & Glantz, 1997).

Objective

This CPG has been developed to serve as a useful tool for doctors and other health professionals in Malaysia to treat tobacco dependence in various settings, including hospitals, clinics or pharmacies. Adoption of this evidence-based guideline is hopes to maximize the success rate of tobacco cessation. However, this CPG is not meant as a substitute for clinical judgement and clinicians are recommended to individualize their treatment strategies.

This CPG will be reviewed every two years and updated with the most recent development if the need arises.

2. GUIDELINE DEVELOPMENT METHODOLOGY

This guideline is based on a combination of 2 methods, namely adaptation from the clinical practice guidelines (CPGs) as mentioned below and incorporation of the latest literature review.

The adaptation were from: 1. Treating Tobacco Use and Dependence 2000,US Department of Health and Human services (Fiore et al., 2000) 2. Guideline for smoking cessation 2001, New Zealand National Advisory Committee on Health and Disability. 3. American Psychiatric Association. Practice guideline for the treatment of patients with nicotine dependence 1996.

These reviewed CPGs provided data up to the year of 1999. Systematic search was done looking at the latest literature up to May 2001.The systematic search was on Medline database search, Cochrane review (up to early September 2001) and Yale search based mesh words on reports on nicotine or tobacco treatment, medications, and clinical management. Our search revealed 120 articles published in peer-reviewed journals.

The evidence level used is adapted from The US/Canada Preventive Services Task Force

Level of Evidence Scale I II-1 II-2 II-3

Evidence obtained from at least one properly randomised controlled trial Evidence obtained from well-designed controlled trials without randomisation Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one research group Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence

III

Opinions of respected authorities, based on clinical experienced; descriptive studies and case reports; or reports of expert committees.

3. ASSESSMENT OF TOBACCO USE

The first step in treating tobacco use and dependence is to identify tobacco users. All patients should be asked if they use tobacco and should have their tobacco-use status documented on a regular basis. Evidence has shown that this significantly increases rates of clinician intervention (Fiore et al., 1995; Ahluwalia, 1997; Ahluwalia et al., 1999)(Level I).

This clinical practice guideline is organized to provide the clinician with simple, but effective interventions for all of these patients.

The assessments are to look for: i. Level of addiction (using Fagerstrom Questionnaires + number of cigarette smoked) -Appendix 1 ii. Readiness for quitting (Miller & Rollnick, 1991)

Screening for current or past tobacco use will result in four possible responses: i. the patient uses tobacco and is now willing to make a quit attempt; ii. the patient uses tobacco but is not now willing to make a quit attempt; iii. the patient once used tobacco but has since quit; iv. the patient never regularly used tobacco.

4. PATIENTS WILLING TO QUIT

There are 2 types of clinical intervention depending on the intensity of intervention and level of service provided. They are: i. Brief clinical intervention ii. Intensive clinical intervention

4.1 Brief Clinical Intervention

Brief clinical intervention by the physician increases quit rates effectively (Fiore et al., 2000) (Level I). It is vital to change clinical culture and practice patterns to ensure that

every patient who uses tobacco is identified and offered treatment. Brief intervention can be divided into treatment either non-pharmacological, pharmacological or combined.

4.11 Non-pharmacological intervention

Every tobacco user should be offered at least a brief intervention whether or not he or she is referred to an intensive intervention as this has been proven to increase overall tobacco abstinence rates (Robinson et al., 1995; Ahluwalia et al., 1999). There is a strong doseresponse relationship between the session length of person-to-person contact and successful treatment outcomes (Fiore et al., 2000). Intensive interventions are more effective than brief interventions and should be used whenever possible (Fiore et al., 2000). Person-to-person treatment delivered for four or more sessions appears especially effective in increasing abstinence rates. Therefore, if feasible, clinicians should strive to meet four or more times with individuals quitting tobacco use.

Individual and group counselling formats are effective and should be used in smoking cessation interventions. Smoking cessation interventions that are delivered in multiple formats increase abstinence rates and should be encouraged. Studies have shown that individual counselling resulted in higher abstinence rates as compared to group or phone counselling and self-help (Fiore et al., 2000) (Level I).

The five major steps (the 5 As) to intervention in the primary care setting are described below. The strategies are designed to be brief and minimal clinicians time is required (Glynn & Manley, 1989; Glynn et al., 1990).

Table 1. The 5 As for brief intervention

1.

Ask about tobacco use: Identify and document tobacco use status for every patient at every visit.

What needs to be done? Expand the vital signs to include tobacco use or use an alternative universal identification system (e.g., stickers on patient charts).

2.

Advise to quit: In a clear, strong and personalized manner urge every tobacco user to quit.

Advice should be: Clear"I think it is important for you to quit smoking now and I can help you." "Cutting down while you are ill is not enough." Strong"As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The clinic staff and I will help you." Personalised Tie tobacco use to current health/illness, and/or its social and economic costs, motivation level/readiness to quit, and/or the impact of tobacco use on children and others in the household.

3.

Assess willingness to make a quit attempt:

Is the tobacco user wi lling to make a quit attempt at this time?

If the patient is willing to make a quit attempt at this time, provide assistance If the patient will participate in an intensive treatment, deliver such a treatment or refer to an intensive intervention. If the patient clearly states he or she is unwilling to make a quit attempt at this time, provide a motivational intervention. Refer page 15-16. If the patient is a member of a special population (e.g., adolescent, pregnant smoker), consider providing additional information.

4.

Assist in quit attempt:

For the patient willing to make a quit attempt, use counselling with pharmacotherapy (when indicated) to help him or her quit.

Preparations for quitting: Set a quit date. Ideally, the quit date should be within 2 weeks. Reduce the number of cigarettes gradually before the set date. Tell family, friends, and co-workers about quitting and request understanding and support. Also,

help patient obtain extra-treatment social support from self-help groups. Other smokers in the household. Patients should encourage household members to quit with them or not smoke in their presence to minimize risk of treatment failure and exposure to second-hand smoking. Advice patient to remove tobacco products from his or her environment. Prior to quitting, avoid smoking in places where a lot of patients time is spent (e.g., work, home, car). Provide a supportive healthcare environment while encouraging the patient in his or her quit attempt. Anticipate challenges to planned quit attempt, particularly during the critical first few weeks. These include nicotine withdrawal symptoms. Discuss challenges/triggers and how patient will successfully overcome them. Provide patients with problem solving/skills training. Abstinence. Total abstinence is essential. Not even a single puff after the quit date. Past quit experience. Identify what helped and what hurt in previous quit attempts. Alcohol. Since alcohol can cause relapse, the patient should consider limiting/abstaining from alcohol while quitting. Recommend the use of approved pharmacotherapies, if indicated. Explain how these medications increase smoking cessation success and reduce withdrawal symptoms. Provide supplementary materials.

5.

Arrange follow-up:

Schedule follow-up contact, preferably within the first week after the quit date.

Timing. Follow-up contact should occur soon after the quit date, preferably during the first week. Subsequent follow-ups are recommended weekly within the first month, and then every two weeks for the 2nd and 3rd month, and monthly after that up to 6 months.

For those who successfully quit, schedule follow-up contact, either in person or via telephone. Actions during follow-up contact. Congratulate success. If tobacco use has occurred, review circumstances an d elicit recommitment to total abstinence. Remind patient that a lapse can be used as a learning experience. Identify problems already encountered and anticipate challenges in the immediate future. Assess pharmacotherapy use and problems. Consider using more intensive treatment, if not available, referral is indicated.

Adapted from Fiore et al., 2000.

Who Should Deliver The Service?

Abstinence rate is better when smoking cessation interventions are delivered by health care providers as compared when there is no clinician involved (e.g., self-help interventions). However, studies have shown that interventions by doctors are costeffective and their non-pharmacological interventions produced better abstinence rates than those by other healthcare personnel (Silagy et al, Cochrane Library 2001; US Department of Health and Human Services, Nov 2000)(Level 1). Therefore, doctors should take the lead role in tobacco cessation programs involving a multidisciplinary team.

4.1.2 Pharmacological Intervention

Our expert committee have reviewed research papers and also from our clinical experience in Malaysia we are in the opinion that all smokers attempting to quit with scores from Modified Fagerstroms questionnaire (Appendix 1) of 4 should be offered pharmacotherapy (Level II). If and smoking > 10 cigarettes per day pharmacotherapy is considered in smokers with Fagerstroms score < 4 or smokes < 10 cigarettes/day, clinicians may use a lowered dose.

Agents proven to be efficacious which are recommended as first line agents for pharmacotherapy includes nicotine replacement therapies (NRT, e.g., gum, patch and inhaler) and sustained release (SR) bupropion(Fiore et al., 2000) (Level I).

Choice of a specific first-line pharmacotherapy must be guided by factors such as clinicians familiarity with the medications, contraindications for selected patients, patient preference, previous patient experience with a specific pharmacotherapy (positive or negative), and patient characteristics (e.g., history of depression, concerns about weight gain (Henningfield, 1995; Hughes & Goldstein, 1999). All allied-health care providers should be supervised by physician when pharmacotherapy is instituted in concordance with the existing law. Currently all the NRTs are listed under class C of the Poison Act 1952.

Special consideration should be given before using pharmacotherapy in selected populations: having medical contraindications (recent myocardial infarction, life-threatening arrhythmia, unstable or worsening angina, recent cerebrovascular accident or hypersensitivity to nicotine (Benowitz et al., 1997; Mahmarian et al., 1997) pregnant/breastfeeding women (Windsor et al.,1985: Walsh et al., 1997) adolescent smokers (Pierce et al., 1998)

Patients with hypertension, stable angina pectoris, cerebrovascular accident, occlusive peripheral arterial disease, heart failure, hyperthyroidism, diabetes mellitus, renal or hepatic impairment or peptic ulcer need closer monitoring (Hughes & Goldstein, 1999).

Table 2. Clinical use of nicotine gum

Patient selection Precautions

Appropriate as a first-line pharmacotherapy for smoking cessation. Pregnancy Pregnant smokers should be encouraged to quit first without

pharmacologic treatment. Nicotine gum should be used during pregnancy only if the increased likelihood of smoking abstinence, with its potential benefits, outweighs the risk of nicotine replacement and potential concomitant smoking. Similar factors should be considered in lactating women (FDA Class D) Appendix 3 Cardiovascular diseases. NRT is not an independent risk factor for acute myocardial events, but it should be used with caution among certain cardiovascular patient groups: those in the immediate (within 2 weeks) post myocardial infarction period, those with serio us arrhythmias, and those with serious or worsening angina pectoris. Side effects. Common side effects of nicotine chewing gum include mouth soreness, hiccups, dyspepsia, and jaw ache. These effects are generally mild and transient, and often can be alleviated by correcting the patients chewing technique (see prescribing instructions below). Dosage Nicotine gum is available in 2 mg and 4 mg (per piece) doses. The 2 mg gum is recommended for patients smoking less than 20 cigarettes per day, while the 4 mg gum is recommended for patients smoking 20 or more cigarettes per day. Generally, the gum should be used for up to 12 weeks with no more than 24 pieces/day. Clinicians should tailor the dosage and duration of therapy to fit the needs of each patient. Availability Prescribing instructions Nicorette 2 and 4 mg Chewing technique. Gum should be chewed slowly until a peppery or minty taste emerges, then parked between cheek and gum to facilitate nicotine absorption through the oral mucosa. Gum should be slowly and intermittently chewed and parked for about 30 minutes or until the taste dissipates. - Appendix 4. Absorption. Eating and drinking anything except water should be avoided for 15 minutes before and during chewing as acidic beverages (e.g., coffee, juices, soft drinks) interfere with the buccal absorption of nicotine. Scheduling of dose. Patients often do not use enough gum to get the maximum benefit: they chew too few pieces per day and they do not use the gum for a sufficient number of weeks. Instructions to chew the gum on a fixed schedule (at least one piece every 1-2 hours during waking hours) for at least 1-3 months may be more beneficial than when necessary.

Adapted from Fiore et al., 2000.

10

Table 3. Clinical use of the nicotine patch

Patient selection Precautions Appropriate as a first-line pharmacotherapy for smoking cessation. Pregnancy. Pregnant smokers should be encouraged to quit first without pharmacological treatment. The nicotine patch should be used during pregnancy only if the increased likelihood of smoking abstinence, with its potential benefits, outweighs the risk of nicotine replacement and potential concomitant smoking. Similar factors should be considered in lactating women. (FDA Class C) Cardiovascular diseases. As per gum Side effects Skin reactions. Up to 50% of patients using the nicotine patch will have a local skin reaction. Skin reactions are usually mild and self-limiting, but may worsen over the course of therapy. Local treatment with hydrocortisone cream (1%) or triamcinolone cream (0.5%) and rotating patch sites may reduce such local reactions. In less than 5% of patients, such reactions require the discontinuation of nicotine patch treatment. Other side effect: Insomnia. Dosage Treatment of 8 weeks or less has been shown to be as efficacious as longer treatment periods. 16- and 24-hour patches are of comparable efficacy. Clinicians should consider individualizing treatment based on specific patient characteristics such as previous experience with the patch, amo unt smoked, degree of addictiveness, etc. Finally, clinicians should consider starting treatment on a lower patch dose in patients smoking 10 or fewer cigarettes per day. Availability Nicotinell TTS30,20,10 (21, 14 and 7 mg, respectively), Nicorette 15,10 and 5 mg 20 cig/day Nicotinell TTS TTS30 TTS20 TTS10 < 20 cig/day TTS20 TTS10 TTS10 Duration (weeks) 1-4 5-8 9-12

Nicorette Prescribing instructions

15 mg x 8 weeks, then 10 mg x 2 weeks and finally 5 mg x 2 weeks Location. At the start of each day, the patient should place a new patch on a relatively hairless location, typically between the neck and waist. Activities. No restrictions while using the patch. Time. Patches should be applied as soon as the patient wakes on their quit day. In patients who experience sleep disruption, advise the patient to remove the 24hour patch prior to bedtime or use the 16-hour patch.

Adapted from Fiore et al., 2000.

11

Table 4. Clinical use of the nicotine inhaler

Patient selection Precautions

Appropriate as a first-line pharmacotherapy for smoking cessation. Pregnancy and cardiovascular diseases. As for nicotine gum.

Side effects

Local irritation reactions. Local irritation in the mouth and throat was observed in 40% of patients using the nicotine inhaler. Coughing and rhinitis occur in 32% and 23%, respectively. Severity was generally rated as mild, and the frequency of such symptoms declined with continued use.

Dosage

A dose from the nicotine inhaler consists of a puff or inhalation. Each cartridge delivers 4 mg of nicotine over 80 inhalations. Recommended dosage is 6-16 cartridges/day. Recommended duration of therapy is up to 6 months. Instruct patient to taper dosage during the final 3 months of treatment.

Availability Prescribing instructions

4 mg/cartridge Ambient temperature. The inhaler and cartridges should be kept at room temperature. Duration. Use is recommended for up to 6 months with gradual reduction in frequency of use over the last 6-12 weeks of treatment. Absorption. Acidic beverages (e.g., coffee, juices, soft drinks) interfere with the buccal absorption of nicotine, so eating and drinking anything except water should be avoided for 15 minutes before and during inhalation. Best effects. Best effects are achieved by frequent puffing.

Adapted from Fiore et al., 2000.

12

Table 5. Clinical use of bupropion SR

Patient selection Precautions

Appropriate as a first-line pharmacotherapy for smoking cessation. Pregnant smokers should be encouraged to quit first without pharmacologic treatment. Bupropion SR should be used during pregnancy only if the increased likelihood of smoking abstinence, with its potential benefits, outweighs the risk of bupropion SR treatment and potential concomitant smoking. Similar factors should be consi dered in lactating women (FDA Class B). Cardiovascular diseases .Generally well tolerated; infrequent reports of hypertension. Side effects .The most common side effects reported by bupropion SR users were insomnia (35-40%) and dry mouth (10%). Contraindications .Bupropion SR is contraindicated in individuals with a history of seizure disorder, a history of an eating disorder, who are using another form of bupropion or who have used an MAO inhibitor in the past 14 days.

Dosage

Patients should begin with a dose of 150 mg q AM for 3 days, then increase to 150 mg b.i.d. Dosing at 150 mg b.i.d. should continue for 7-12 weeks following the quit date. Unlike nicotine replacement products, patients should begin bupropion SR treatment 1-2 weeks before they quit smoking. For maintenance therapy, consider bupropion SR 150 mg b.i.d. for up to 6 months.

Availability Prescribing instructions

Not yet available Cessation prior to quit date .Recognize that some patients will lose their desire to smoke prior to their quit date, or will spontaneously reduce the amount they smoke. Scheduling of dose .If insomnia is marked, taking the PM dose earlier (in the afternoon, at least 8 hours after the first dose) may provide some relief. Alcohol .Use alcohol only in moderation.

Adapted from Fiore et al., 2000.

13

Combination of agents

Strategies of combining agents available (e.g., two NRTs, a non-NRT, e.g. bupropion with a NRT) may be more efficacious. For example, combining the nicotine patch with a selfadministered form of nicotine replacement therapy (either the nicotine gum or nicotine inhaler) is more efficacious than a single form of nicotine replacement, and patients should be encouraged to use such combined treatments if they are unable to quit using a single type of first-line pharmacotherapy (Silagy C et al., 2001, Covey LS et al., 2000, Hughes et al., 2001) (Level I).

4.2 Intensive Clinical Interventions

Evidence shows that intensive tobacco dependence treatment is more effective than brief treatment. This could be achieved by increasing the length of individual treatment sessions, the number of treatment sessions and specialized behavioural therapies. Intensive clinical interventions could be provided by any suitably trained doctors and other healthcare providers who have the resources available to give intensive interventions and are appropriate for any tobacco user willing to participate in them (Fiore et al., 2000) (Level I).

Components of an intensive intervention

Assessments should ensure that tobacco users are willing to quit using an intensive treatment program. Other assessments can provide information useful in counselling (eg. stress, weight reduction and other medical conditions).

Multidisciplinary team of clinicians and healthcare providers who deliver messages about health risks, benefits of pharmacotherapy and behavioural therapies. The intensity of the program should be longer than 10 minutes per session, minimum 4 sessions Either individual or group counselling may be used. Proactive telephone counselling as well as other methods of communications should be considered Use of adjuvant self-help material is optional. Follow-up assessment intervention procedures should be used

14

Specialized counselling such as cognitive behavioural therapy Every smo ker should be encouraged to use pharmacotherapies endorsed in this guideline.

Three specific types of counselling and behavioural therapy categories yield statistically significant increases in abstinence rates relative to no-contact (e.g., untreated control conditions) (Davis et al., 1984; Platt et al., 1997). These categories are:

providing practical counselling such as problem solving/skills training/ relapse prevention/stress management providing support during a smokers direct contact with a clinician (intra-treatment social support intervening to increase social support in the smokers environment (extratreatment social support)

5. FOR THE PATIENT UNWILLING TO QUIT

Motivational interventions are most likely to be successful when the clinician is empathic, promotes patient autonomy (e.g., choice among options), avoids arguments, and supports the patients self-efficacy (e.g., by identifying previous successes in behaviour change efforts) (Miller & Rolnick , 1991; Rundmo et al., 1997; Colby et al., 1998).

Patients unwilling to make a quit attempt during a visit may be due to: lack of information about the harmful effects of tobacco, may be demoralized because of previous relapse. lack the required financial resources may have fears or concerns about quitting

Such patients may respond to a motivational intervention built around the 5 Rs: relevance, risks, rewards, roadblocks, and repetition.

15

Table 6. The 5 Rs for enhancing motivation to quit tobacco

Relevance Encourage the patient to indicate why quitting is personally relevant, being as specific as possible. Motivational information has the greatest impact if it is relevant to a patients disease status or risk, family or social situation (e.g., having children in the home), health concerns, age, gender, and other important patient characteristics (e.g., prior quitting experience, personal barriers to cessation). Risks The clinician should ask the patient to identify potential negative consequences of tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient. The clinician should emphasize that switching to low-tar/low-nicotine cigarettes or other forms of tobacco (e.g., smokeless tobacco, cigars, rokok daun and pipes) will still have similar risks. Examples of risks are: o Short-term risks: Shortness of breath, exacerbation of asthma, harm to pregnancy, impotence, infertility, increased serum carbon monoxide. o Long-term risks: Heart attacks and strokes, lung and other cancers (larynx, oral cavity, pharynx, oesophagus, pancreas, bladder, cervix), chronic obstructive pulmonary diseases (chronic bronchitis and emphysema), long-term disability and need for extended care. o Environmental risks: Increased risk of lung cancer and heart disease in spouses; higher rates of smoking by children of tobacco users; increased risk for low birth weight, SIDS, asthma, middle ear disease, and respiratory infections in children of smokers. Rewards The clinician should ask the patient to identify potential benefits of stopping tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient. Examples of rewards follow: o o o o o o o o o o o o Roadblocks The clinician should ask the patient to identify barriers to quitting and note elements of treatment (problem solving, pharmacotherapy) that could address barriers. Typical barriers might include: Improved health. Improved sense of smell. Feel better about yourself. Can stop worrying about quitting. Food will taste better. Save money. Home, car, clothing, breath will smell better. Set a good example for children. Have healthier babies and children. Not worry about exposing others to smoke. Perform better in physical activities. Reduced wrinkling/aging of skin.

16

o o o o o o o Repetition

Withdrawal symptoms. Fear of failure. Weight gain. Lack of support. Depression. Enjoyment of tobacco. Cost of treatment.

The motivational intervention should be repeated every time an unmotivated patient visits the clinic setting. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful.

Adapted from Fiore et al., 2000.

6. PATIENT WHO HAS RECENTLY QUIT

Clinicians should provide brief effective relapse prevention interventions due to the chronic relapsing nature of tobacco dependence (Brandon et al., 1990; Zhu et al., 1996; Westman et al., 1997).

When clinicians encounter a patient who has quit tobacco use recently, they should: i. reinforce the patients decision to quit ii. review with patient the benefits of quitting iii. assist the patient in resolving any residual problems arising from quitting.

Although most relapse occurs early (within first 3 months) in the quitting process, some relapse occurs months or even years after the quit date (Hatziandreu et al., 1990; Brandon et al., 1990). Therefore, clinicians should continuously engage in relapse prevention interventions.

Relapse prevention interventions can be delivered by means of scheduled clinic visits, telephone calls, or any time the clinician encounters an ex-tobacco user. There are two practices of relapse prevention, either minimal or intensive.

17

Minimal practice relapse prevention

This is appropriate for most recent quitters and can be addressed briefly during a coincident clinic visit or a scheduled follo w-up visit. Similarly, the 5 Rs strategy should be used to prevent relapse. Patients should be encouraged to report difficulties promptly (e.g., lapses, depression, medication side-effects) while continuing efforts to remain abstinent.

When encountering a recent quitter, use open-ended questions designed to initiate patient problem solving (e.g., How has stopping tobacco use helped you?).

The clinician should encourage the patients to actively discuss the topics below: i. The benefits, including potential health benefits, the patient may derive from cessation. ii. Any success the patient has had in quitting (duration of abstinence, reduction in withdrawal, etc.). iii. The problems encountered or anticipated threats to maintaining abstinence (e.g., depression, weight gain, alcohol, other tobacco users in the household).

Every ex-tobacco user undergoing relapse prevention should be congratulated on any success and strongly encouraged to remain abstinent.

Intensive practice relapse prevention

Intensive relapse prevention components are individualized based on information obtained about problems the patient has encountered in maintaining abstinence. These interventions may be delivered during a dedicated follow-up contact (in-person or by telephone) or through a specialized clinic or program. Specific interventions

recommended for problems related to maintaining smoking cessation are listed in Table 7. Long-term smoking cessation pharmacotherapy should be considered as a strategy to reduce the likelihood of relapse.

18

Table 7. Problem-related interventions to maintain smoking cessation

Problems Lack of support for cessation

Recommended interventions Schedule follow-up visits or telephone calls with the patient.

Help the patient identify sources of support within his or her environment. Refer the patient to an appropriate organization that offers cessation counselling or support. Negative mood or Depression Strong or prolonged withdrawal symptoms If significant, provide counselling, prescribe appropriate medications, or refer the patient to a specialist. If the patient reports prolonged craving or other withdrawal symptoms, consider extending the use of an approved pharmacotherapy or adding/combining pharmacological medications to reduce strong withdrawal symptoms. Weight gain Recommend starting or increasing physical activity; discourage strict dieting. Reassure the patient that some weight gain after quitting is common and appears to be self-limiting. Emphasize the importance of a healthy diet. Flagging motivation/ feeling deprived Maintain the patient on pharmacotherapy known to delay weight gain (e.g., bupropion SR, NRTs, particularly nicotine gum). Refer the patient to a specialist or program. Reassure the patient that these feelings are common. Recommend rewarding activities. Probe to ensure that the patient is not engaged in periodic tobacco use. Emphasize that beginning to smoke (even a puff) will increase urges and make quitting more difficult.

Adapted from Fiore et al., 2000.

7. SPECIAL POPULATIONS

7.1 Female smokers

Smoking cessation clinical trials reveal that the same treatments benefit both men and women (Bjornson et al., 1995; Gritz et al., 1998). However, research suggests that some treatments are less efficacious in women than in men (e.g., NRTs) (Perkins et al., 1996;

19

Wetter et al., 1999). Although research shows that women benefit from the same interventions as men, women may face different stressors and barriers to quitting that should be addressed in treatment. These include greater likelihood of depression, greater weight control concerns, hormonal cycles, and others (Gritz et al., 1996). This suggests that women may benefit from tobacco dependence treatments that address these topics, although few studies have examined programs targeted to one gender. Women who are considering pregnancy may be especially receptive to tobacco cessation.

Pregnant Women

All pregnant women should be strongly advised to quit smoking due to the adverse effects of smoking to the pregnancy and the foetus. Smoking has been implicated in the etiology of abruptio placenta, placenta previa, spontaneous abortion, premature delivery, and stillbirth. Intrauterine growth retardation is the most strongly documented adverse effect of smoking during pregnancy. Prenatal smoking is thought to account for about 18% of cases of low birth weight (<2500 g), and also increases risk of premature delivery, respiratory distress syndrome, and sudden infant death syndrome (Sexton M and Hebel JR 1984, Ershoff DH, Quinn VP, Mullen PD, et al 1990). A reduction in tobacco use increases birth weight, decreases the incidence of low birth weight infants and is cost effective. Cognitive ability is decreased in children whose mothers have smoked during gestation (Levin & Slotkin, 1998). Exposure to second hand smoke (passive smoking) may also have an adverse effect on birth weight (Fortier, et al 1994).

All pregnant smokers should be offered intensive interventions (Fortier, et al 1994). Although abstinence early in pregnancy will produce the greatest benefits to the foetus and expectant mother, quitting at any point in pregnancy can yield benefits. Therefore, clinicians should offer effective smoking cessation interventions to pregnant smokers at the first prenatal visit as well as throughout the course of pregnancy (Baric L 1976, Burling et al T 1984, McArthur C 1987, Lilley J and Forster DP1986). Pharmacotherapy should be considered when a pregnant woman is otherwise unable to quit, and when the likelihood of quitting, with its potential benefits, outweighs the risks of the pharmacotherapy and potential continued smoking (Baric L 1976, Burling T et al., 1984, McArthur C 1987, Lilley J and Forster DP 1986). Consultation with medical specialist is recommended before initiating pharmacotherapy.

20

7.2. Hospitalised smokers

Hospitalisation provides a powerful opportunity to quit smoking. It is vital that they attempt to quit smoking, as smoking may interfere with their recovery. Augmented smoking cessation treatments e.g., self-help via brochure or audio/videotape, chart, prompt reminding physician to advise smoking cessation, pharmacotherapy, hospital counselling, and post-discharge counselling telephone calls have been shown to be effective. Among cardiac patients, second heart attacks are more common in those who continue to smoke. (Lightwood, 1997) Lung, head, and neck cancer patients who are successfully treated, but who continue to smoke, are at higher risk for a second cancer.( Gritz et al., 1991; Browman et al., 1993; Richardson et al., 1993; Fujisawa et al., 1999; Kawahara et al., 1998). Additionally, smoking delays bone and wound healing( Jones, 1985; Grossi et al., 1995; Chang et al., 1996).

Hospitalised patients may be particularly motivated to make a quit attempt for two reasons. Firstly, the illness causing the hospitalisation may have been due to or exacerbated by smoking, highlighting the patients personal vulnerability to the health risks of smoking (Hurt et al., 1992; Stevens 1993). Secondly, all hospitals in Malaysia are designated smoke-free areas (CTPR 2003). Patients in long-term care facilities such as mental health institution, old folks home, rehabilitation centres should also receive tobacco cessation interventions. Suggested interventions for hospitalised patients are as follows: Ask each patient on admission if he or she uses tobacco and document tobacco use status. For current tobacco users, record tobacco use status on the admission problem list and as a discharge diagnosis. Use counselling and pharmacotherapy to assist all tobacco users to maintain abstinence and to treat withdrawal symptoms accordingly. Provide advice and assistance on how to quit during hospitalisation and remain abstinent after discharge.

21

7.3 Psychiatric patients.

Smoking cessation treatments sho uld be provided to all smokers with psychiatric morbidity because of beneficial effects of intervention (Addington et al,1998; Kelly & McCreadie,2000; McEvoy & Joseph,2000). Bupropion SR is a drug of choice for smokers with depression. Evidence indicates that smoking cessation interventions do not interfere with recovery from chemical dependency. Therefore, smokers receiving treatment for chemical dependency should be provided smoking cessation treatments shown to be effective in this guideline, including both counselling and pharmacotherapy (Evins & Tisdale, 1999; Kelly & Mc Creadie, 2001) (Level II-3).

Patients with psychiatric illness have a higher prevalence of smoking compare to general population e.g., 3 times higher in those with schizophrenia (Hughes et al,1986; Dalack et al, 1996). 68% of patients with schizophrenia who smoked were classified as heavy

smokers compared with 11% of those in the general population (Kelly et al, 2000). Smoking had been shown to decrease plasma levels of neuroleptics by inducing hepatic microsomal enzymes (Solokangas et al,1997). Therefore, patients who smoke require larger doses of drugs than non-smokers (Lohr & Flynn, 1992). A substantial proportion of the income of smokers with schizophrenia is spent on cigarettes (Mc Creadie & Kelly, 2000). Smoking ban on in-patient psychiatric units has met with some success but the most severely addicted patients are extremely resourceful and continue to smoke(Lavin et al, 1996). The symptoms of nicotine withdrawal can confuse or exacerbate the

symptoms of schizophrenia. The use of NRT can substantially reduce these symptoms (Dalack & Meadow-Woodruf, 1999). Buproprion SR, alone or combination with NRT is the choice pharmacotherapy for tobacco cessation in these patients (Joren et al,1999; Evins & Tisdale,1999).

About 30% of those seeking smoking cessation in general population have a history of depression (Covey et al, 1998, Breckenridge, 1990). Smoking cessation may elicit or exacerbate depression among patients with a prior history of affective disorder (Hall et al,1993, Glassman et al1993). Smokers with depression have a heightened risk of

relapse of depression if they quit smoking. Buproprion SR, alone or combination with NRT is recommended. Smokers with psychiatric and other chemical or substance dependence (eg. alcohol, should be referred to relevant specialist.

22

7.4 Children and adolescents

Healthcare providers should screen paediatric and adolescent patients, and their parents, for tobacco use and exposure. Counselling and behavioural interventions that have been shown to be effective are recommended for children and adolescents (Fiore et al., 2000) (Level I). The contents of these interventions should be modified according to the age of the child (Lawendowski 1998). When treating adolescent smokers, clinicians may consider NRT or bupropion SR when there is evidence of nicotine dependence and desire to quit (Fiore et al., 2000) (Level III). However, because of the psychosocial behavioural aspects of smoking in adolescents, clinicians should be very sure of the patients tobacco dependence and intention to quit before instituting pharmacotherapy. Special

consideration should be given to the degree of dependence, number of cigarettes per day, and body weight.

Healthcare providers in a paediatric setting should offer smoking cessation advice and interventions to parents or guardians to limit childrens exposure to second-hand smoke (Fiore et al., 2000) (Level I).

Youth smokers of today are likely to become regular smokers of tomorrow (NIDA,1993). It is estimated that 90% of smokers start smoking before the age of18. Hence it is important to reduce the amount of tobacco use among youth so as to decrease the rate of nicotine dependence and subsequent morbidity and mortality in future adults (Riley et al 1996).

Adolescents are likely to model parents behaviour and adopt similar norms. Youth who have family members and close friends who smoke have a stronger predilection to regular smoking. The role of socio-economic and demographic factors in smoking

initiation/experimentation is well documented. These factors include low socio-economic status, smoking among family and friends, low self esteem, poor academic performances and behavioural problems (Flay et al., 1994).

7.5 Elderly

Smoking cessation in older smokers can reduce the risk of myocardial infarction, death from coronary heart disease, and lung cancer. Moreover, abstinence can promote more

23

rapid recovery from illnesses that are exacerbated by smoking and can improve cerebral circulation (Hermanson et al., 1988; Rogers et al., 1985). In fact, age does not appear to diminish the benefits of quitting smoking (Hermanson et al 1988).

Counselling interventions, (Burton et al., 1995; Morgan et al., 1996; Wetter et al., 1990) physician advice, (Morgan et al., 1996) telephone counselling, (Rimer et al., 1994; OsipKlein et al., 1997) and the nicotine patch (Orleans et al., 1994) have all been shown to be effective in treating tobacco use in adults ages 50 and older.

8. MANAGEMENT OF WEIGHT GAIN

For smokers who are greatly concerned about weight gain, it may be most appropriate to prescribe or recommend bupropion SR or NRT, in particular nicotine gum, which have been shown to delay weight gain after quitting (Fiore et al., 2000) (Level I).

Quitting smoking is often followed by weight gain hence, health professionals involved should: i. note that the health risks of weight gain are small when compared to the risks of continued smoking ii. recommend physical activities and a healthy diet to control weight iii. recommend that patients concentrate primarily on smoking cessation, not weight control, until ex-smokers are confident that they will not return to smoking.

A majority of smokers gain weight after they quit smoking. Most will gain less than 5 kilograms. It has been reported that about 10% of quitters gain up to 15 kilograms (Froom et al., 1998). However, weight gain that follows smoking cessation is a negligible health threat compared with the risks of continued smoking. Weight gain that follows smoking cessation is a negligible health threat compared with the risks of continued smoking (Williamson et al., 1981; Burnette et al., 1988). Post-cessation weight gain appears to be caused both by increased intake and by metabolic adjustments. The involvement of metabolic mechanisms suggest that even if smokers do not increase their caloric intake upon quitting, they will, on average, gain some weight (Gray et al., 1995; Hatsukami et al., 1993; Hofstette et al., 1986; Klesges et al., 1992; Moffatt et al., 1981).

24

9. REFERENCES Ahluwalia JS. Reaching the medically underserved with the AHCPR guideline. Tob Control 1997; 6(Suppl 1):S29-S32. Ahluwalia J, Gibson C, Kenney R, Wallace D, Resnicow K. Smoking status as a vital sign. J Gen Intern Med 1999;14(7):402-8. Baric L, MacArthur C, Sherwood M. A study of health education aspects of smoking in pregnancy. Int J Health Educ 1976; 19 (Suppl 2): 1-15 Benowitz NL, Gourlay SG. Cardiovascular toxicity of nicotine: implications for nicotine replacement therapy. J Am Coll Cardiol 1997;29(7):1422-31. Bjornson W, Rand C, Connett JE, Lindgren P, Nides M, Pope F, et al. Gender differences in smoking cessation after 3 years in the Lung Health Study. Am J Public Health 1995;85(2):223-30. BreckenridgeJS. Smoking by outpatients. Hosp Community Psychiatry 1990;41(4):454- 5. Brandon TH, Tiffany ST, Obremski K, Baker TB. Postcessation cigarette use: the process of relapse. Addict Behav 1990;15:105-14. Browman GP, Wong G, Hodson I, Sathya J, Russell R, McAlpine L, et al. Influence of cigarette smoking on the efficacy of radiation therapy in head and neck cancer. N Engl J Med 1993;328(3):159-63. Burling T, et al. Changes in smoking during pregnancy. Paper presented at the Society for Behavioral Medicine, Philadelphia, PA, May 25, 1984 Burnette MM, Meilahn E, Wing RR, Kuller LH. Smoking cessation, weight gain, and changes in cardiovascular risk factors during menopause: the Healthy Women Study. Am J Public Health 1998;88(1):93-6. Burton LC, Paglia MJ, German PS, Shapiro S, Damiano AM, The Medicare Preventive Services Research Team. The effect among older persons of a general preventive visit on three health behaviors: smoking, excessive alcohol drinking, and sedentary lifestyle. Prev Med 1995;24(5):492-7. Centers for Disease Control and Prevention. Health objectives for the nation cigarette smoking among adultsUnited States, 1993. MMWR Morb Mortal Wkly Rep 1994;43(50):925-30. Centers for Disease Control and Prevention. Perspectives in disease prevention and health promotion smoking-attributable mortality and years of potential life lostUnited States, 1984. MMWR Morb Mortal Wkly Rep 1997; 46(20):444-51. Centers for Disease Control and Prevention. Smoking cessation during previous year among adultsUnited States, 1990 and 1991. MMWR Morb Mortal Wkly Rep 1993;42(26):504-7.

25

Chang HC, Zimmerman LH, Beck JM. Impact of chart reminders on smoking cessation practices of pulmonary physicians. Am J Respir Crit Care Med 1995; 152(3):984-7. Colby SM, Barnett NP, Monti PM, Rohsenow DJ, et al. Brief motivational interviewing in a hospital setting for adolescent smoking: a preliminary study. J Consult Clin Psychol 1998;66(3):574-8. Consensus statement US Public Health Service, JAMA June 2000 Covey LS, Glassman AH, Stetner F. Cigarette smoking and major depression. [Review] [28 refs]. J Addict Dis 1998;17(1):35-46. Control of Tobacco Products Regulations 2003 in Food Act 1983. Laws of Malaysia. Davis AL, Faust R, Ordentlich M. Self -help smoking cessation and maintenance programs: a comparative study with 12-month follow-up by the American Lung Association. Am J Public Health 1984;74(11):1212-7. Dalack GW, Meadow-Woodruff JH. Acute feasibility and safety f a smoking reduction strategy for smokers with schizophrenia. Nicotine Tobacco Research. 1999;1:53-57. Dalack GW, Meadow-Woodruff JH. Smoking, smoking withdrawal and schizophrenia: case reports and a review of literature. Schizophrenia Research, 1996; 22:133-141. Eddy DM. Setting priorities for cancer control programs. J Natl Cancer Inst 1986; 76(2):187-199. Ershoff DH, Quinn VP, Mullen PD, et al. Pregnancy and medical cost outcomes of a selfhelp prenatal smoking cessation program in a HMO. Public Health Rep 1990; 105: 340347 Evins AE, Tisdale T. Bupropiion and smoking cessation. American Journal Psychiatry. 1999;156: 798-799. Fergusson DM, Lloyd M. Smoking during pregnancy and its effects on child cognitive ability from the ages of 8 to 12 years. Paediatr Perinatal Epidemiol 1991; 5: 189-200 Fiore MC, Jorenby DE, Schensky AE, Smith SS, Bauer RR, Baker TB. Smoking status as the new vital sign: effect on assessment and intervention in patients who smoke. Mayo Clin Proc 1995;70(3):209-13. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence.Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. June 2000. First National Health and Morbidity Survey (NHMS1) 1985. Ministry of Health, Malaysia Flay B,Hu FB,Siddique O,et al.Differential influenceof parental smoking and friends smoking on adolescent initiation and escalation of smoking. J Health Soc Behav

26

Fortier I, Marcoux S, Brisson J. Passive smoking during pregnancy and the risk of delivering a small-for-gestational-age infant. Am J Epidemiol 1994; 139: 294-301 Froom P, Melamed S, Benbassat J. Smoking cessation and weight gain. [Review] [61 refs]. J Fam Pract 1998;46(6):460-4. Fujisawa T, Lizasa T, et al. Smoking before surgery predicts poor long-term survival in patients with stage I non-small-cell lung carcinomas. J Clin Oncol 1999; 17(7):2086-91. Glassman AH. Cigarette smoking: implications for psychiatric illness. Am J Psychiatry 1993;150(4):546-53. Glynn TJ, Manley MW, Pechacek TF. Physician-initiated smoking cessation program: the National Cancer Institute trials. Prog Clin Biol Res 1990;339:11-25. Glynn TJ, Manley MW. How to help your patients stop smoking: a National Cancer Institute manual for physicians. Bethesda, MD: NIH Publication No. 89-3064. 1989. Gray CL, Cinciripini PM, Cinciripini LG. The relationship of gender, diet patterns, and body type to weight change following smoking reduction: a multivariate approach. J Subst Abuse 1995;7(4):405-23. Gritz E. Smoking and smoking cessation in cancer patients. British Journal of Addict 1991;86:549-54. Gritz ER, Nielsen IR, Brooks LA. Smoking cessation and gender: the influence of physiological, psychological, and behavioral factors. [Review] [86 refs]. J Am Med Womens Assoc 1996;51(1-2):35-42. Gritz E, Thompson B, Emmons K, Ockene J, McLerran DF, Nielsen IR. Gender differences among smokers and quitter in the working well trial. Prev Med 1998; 27:55361. Grossi SG, Genco RJ, Machtei EE, et al. Assessment of risk for periodontal diseases. II. Risk indicators for alveolar bone loss. J Periodontol 1995;66:23-9. Hall SM, Munoz RF, Reus VI, Sees KL. Nicotine, negative affect, and depression. J Consult Clin Psychol 1993;61(5):761-7. Hatsukami D, LaBounty L, Hughes J, Laine D. Effects of tobacco abstinence on food intake among cigarette smokers. Health Psychol 1993;12(6):499-502. Hatziandreu EJ, Pierce JP, Lefkopoulou M, Fiore MC, Mills SL, Novotny TE, et al. Quitting smoking in the United States in 1986. J Natl Cancer Inst 1990; 82(17):1402-6. Hermanson B, Omenn GS, Kronmal RA, Gersh BJ. Beneficial six-year outcome of moking cessation in older men and women with coronary artery disease. Results from the CASS registry. N Engl J Med 1988;319(21):1365-9.

27

Herrera N, Franco R, Herrera L, Partidas A, Rolando R, Fagerstrom KO. Nicotine gum, 2 and 4 mg, for nicotine dependence. A double-blind placebo-controlled trial within a behavior modification support program. Chest 1995; 108(2):447-51. Henningfield JE. Nicotine medications for smoking cessation. [Review] [101 refs]. N Engl J Med 1995;333(18):1196-203. Hjalmarson AIM, Hahn L, Svanberg B. Stopping smoking in pregnancy: effect of a selfhelp manual in controlled trial. Br J Obstet Gynaecol 1991; 98: 260-264 Hofstetter A, Schutz Y, Jequier E, Wahren J. Increased 24-hour energy expenditure in cigarette smokers. N Engl J Med 1986;314(2):79-82. Hughes J, Goldstein MG. Recent advances in the pharmacotherapy of smoking. JAMA 1999;281(1):72-6. Hughes JR, Hatsukami DK, Mitchell JE et al. Prevalence of smoking among psychiatric outpatients. American Journal of Psychiatry, 1986;143: 993-997. Hurt RD, Lauger GG, Offord KP, Bruce BK, Dale LC, McClain FL, et al. An integrated approach to the treatment of nicotine dependence in a medical center setting: description of the initial experience. J Gen Intern Med 1992;7:114-6. Jones RM. Smoking before surgery: the case for stopping [editorial]. BMJ (Clin Res Ed) 1985;290(6484):1763-4. Jorenby,DE, Leischw SJ, Nides MA et al. A controlled trial of sustained release buprenorphine, a nicotine patch, or both for smoking cessation. New England Journal of Medicine. 1999;304:685-691. Kawahara M, Ushijima S, et al. Second primary tumours in more than 2-year disease-free survivors of small-cell lung cancer in Japan: the role of smoking cessation. Br J Cancer 1998;78(3):409-12. Kelly C, McCreadie R. Cigarette smoking and schizophrenia. Advances Psychiatric treatment. 2000;6: 327-331. Klesges LM, Shumaker SA, editors. Proceedings of the national working conference on smoking and body weight. Health Psychol 1992;11(suppl):1-22. Kornitzer M, Kittel F, Dramaix M, Bourdoux P. A double blind study of 2 mg versus 4 mg nicotine-gum in an industrial setting. J Psychosom Res 1987;31(2):171-6. Kviz FJ, Clark MA, Crittenden KS, Freels S, Warnecke RB. Age and readiness to quit smoking. Prev Med 1994;23(2):211-22. Lawendowski LA. A motivational intervention for adolesent smokers. 1998. Preventive Medicine 27, A39-A46 Lavin MR, SirisSG, Mason SE. What is the clinical importance of cigarette smoking in schizophrenia? American Journal Addictions. 1996;5:18-208.

28

Lewin ED, Slotkin TA. Developmental neurotoxicity of nicotine. In: Slider W, Chang LW. Handbook of developmental neurotoxicity. San Diego, California; Academic Press; 1998; 587-615. Lilley J and Forster DP. A randomized controlled trial of individual counselling of smokers in pregnancy. Public Health 1986; 100: 309-315 Lightwood JM, Glantz SA. Short-term economic and health benefits of smoking cessation: myocardial infarction and stroke. Circulation 1997;96(4):1089-96. In primary care practices. Arch Fam Med 1997;6(2):165-72. Lumley J. Advice as a strategy for reducing smoking in pregnancy. In Pregnancy and Childbirth Module (eds. Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP), Cochrane Database of Systematic Reviews: Review No. 03394, 2 October 1993. Published through Cochrane Updates on Disk, Oxford: Update Software, 1993, Disk Issue 2 Mahmarian JJ, Moye LA, Nasser GA, et al. Nicotine patch therapy in smoking cessation reduces the extent of exercise-induced myocardial ischemia. J Am Coll Cardiol 1997;30(1):125-30. Mayer JP, Hawkins B, Todd R. A randomized evaluation of smoking cessation interventions for pregnant women at a WIC clinic. Am J Public Health 1990; 80: 76-78 McArthur C, Newton JR, Knox EG. Effect of anti-smoking health education on infant size at birth: a randomized controlled trial. Br J Obstet Gynaecol 1987; 94: 295-300 McCreadie R. Kelly C. Patients with schizophrenia who smoke. Private disaster, public resource. British Journal Psychiatry.2000;176:109. McEvoy, Joseph P. Schizophrenia, substance misuse and smoking. Current Opinion Psychiatry. 2000;13:15-19. Meichenbaun D, Turk D. Facilitating treatment adherence: a practitioners guidebook. New York: Plenum, 1987. Miller W, Rolnick S. Motivational interviewing: preparing people to change addictive behavior. New York: Guilford, 1991. Moffatt RJ, Owens SG. Cessation from cigarette smoking: changes in body weight, body composition, resting metabolism, and energy consumption. Metabolism 1991;40(5):465-70. Morgan GD, Noll EL, Orleans CT, Rimer BK, Amfoh K, Bonney G. Reaching midlife and older smokers: tailored interventions for routine medical care. Prev Med 1996;25(3):34654. NIDA. National Survey Results on Drug Use From Monitoring The Future Survey,19751992 Vol.2.Bathesda ,Md.:US Dept. of Health and Human Services,Public Heath Services ,NIH;1993

29

Orleans CT, Resch N, Noll E, Keintz MK, Rimer BK, Brown TV, et al. Use of transdermal nicotine in a state-level prescription plan for the elderly. A first look at real-world patch users. JAMA 1994;271(8):601-7. Ossip-Klein DJ, Carosella AM, Krusch DA. Self-help interventions for older smokers. Tob Control 1997;6(3):188-93. Perkins KA. Sex differences in nicotine versus nonnicotine reinforcement as determinants of tobacco smoking. Exp Clin Psychopharmacol 1996;4(2):166-77. Piccittio M. Neurobiology of nicotine, Drugs Alcohol Depend. 1998. Pierce JP, Choi WS, Gilpin E, Farkas AJ, et al. Tobacco industry promotion of cigarettes and adolescent smoking. JAMA 1998;279(7):511-5. Platt S, Tannahill A, Watson J, Fraser E. Effectiveness of antismoking telephone helpline: follow up survey. BMJ 1997;314(7091):1371-5. Prochaska J, Goldstein MG. Process of smoking cessation. Implications for clinicians. Clin Chest Med 1991;12(4):727-35. Richardson G, Tucker M, Venzon D. Smoking cessation after successful treatment of small-cell lung cancer is associated with fewer smoking-related second primary cancers. Ann Intern Med 1993;119(5):383-90. Riley WT, KaugersGE.,Grisius et al,Adult smokeless tobaccouse and ageof onset. Addiction behaviour. 1996 ; 21,135-138 Rimer BK, Orleans CT, Fleisher L, Cristinzio S, Resch N, Telepchak J, et al. Does tailoring matter? The impact of a tailored guide on ratings and short-term smokingrelated outcomes for older smokers. Health Educ Res 1994;9(1):69-84. Robinson MD, Laurent SL, Little JM, Jr. Including smoking status as a new vital sign: it works! J Fam Pract 1995;40(6):556-61. Rogers RL, Meyer JS, Judd BW, et al. Abstention from cigarette smoking improves cerebral perfusion among elderly chronic smokers. JAMA 1985;253(20):2970-4. Rundmo T, Smedslund G, Gotestam KG. Motivation for smoking cessation among the Norwegian public. Addict Behav 1997;22(3):377-86. Schwid SR, Hirvonen MD, Keesey RE. Nicotine effects on body weight: a regulatory perspective. Am J Clin Nutr 1992;55(4):878-884. Salokangas RKR, Saarijarvi S, Taiminen T et al. Effect of smoking on neuroleptics in schizophrenia. Schizophrenia research. 1997;23:55-60. Second National Healthand Morbidity Survey (NHMS2) 1996. Ministry of Health, Malaysia Sexton M and Hebel JR: A clinical trial of change in maternal smoking and its effect on birth weight. JAMA 1984; 251: 911-915

30

Slotkin TA. Fetal nicotine or cocaine exposure; which one is worse? J Pharmacol Exp Ther, 1998; 285(3):931-945 Smith TA, House RFJ, Croghan IT, Gauvin TR, Colligan RC, Offord KP, et al. Nicotine patch therapy in adolescent smokers. Pediatrics 1996;98(4 (Pt 1)):659-67. Stanton WR, Lowe JB, Gillespie AM 1996. Adolescents experiences of smoking cessation. Drug Alcohol Depend. 43. 63-70 Stevens VJ, Glasgow RE, Hollis JF, Lichtenstein E, Vogt TM. A smoking-cessation intervention for hospital patients. Med Care 1993; 31(1):65-72. Tengs T, Adams M, Pliskin J, Safran D, Seigel J, Weinstein M, et al. Five-hundred lifesaving interventions and their cost effectiveness. Risk Anal 1995;15(3):369-90. US Department of Health and Human Services. The health benefits of smoking cessation: A report of the Surgeon General. Atlanta (GA): US Department of Health and Human Services. Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health. DHHS Publication No. (CDC) 90-8416, 1990. US Department of Health and Human Services. Public Health. Treating Tobacco Use and Dependence, A System Approach. Nov 2000. Vetter NJ, Ford D. Smoking prevention among people aged 60 and over: a randomized controlled trial. Age Ageing 1990;19(3):164-8. Walsh RA, Redman S, Brinsmead MW, Byrne JM, Melmeth A. A smoking cessation program at a public antenatal clinic. Am J Public Health 1997; 87(7):1201-4. Westman EC, Behm FM, Simel DL, Rose JE. Smoking behavior on the first day of a quit attempt predicts long-term abstinence. Arch Intern Med 1997;157(3):335-40. Wetter D, Fiore MC, Jorenby D, Kenford S, Smith S, Baker T. Gender differences in smoking. J Consult Clin Psychol 1999;67(4):555-62. Williamson DF, Madans J, Anda RF, Kleinman JC, Giovino GA, Byers T. Smoking cessation and severity of weight gain in a national cohort. N Engl J Med1991;324(11):739-45. Windsor RA, Cutter G, Morris J, Reese Y, Manzella B, Bartlett EE, et al. The effectiveness of smoking cessation methods for smokers in public health maternity clinics: a randomized trial. Am J Public Health 1985;75(12):1389-92. Zhu SH, Stretch V, Balabanis M, Rosbrook B, Sadler G, Pierce JP. Telephone counselling for smoking cessation: effects of single-session and multiple-session interventions. J Consult Clin Psychol 1996;64(1):202-11.

31

ALGORITHM FOR MANAGEMENT OF TOBACCO USE AND DEPENDENCE

Patient Ask about tobacco use Yes No

SMOKER

NON SMOKER

Recently quit Unwilling (Maintenance) to quit (Precontemplation)

Willing to quit (Contemplation)

Advice Assist Arrange

Set quit date (Action)

Relapse prevention

Motivation to quit

1, Behaviour therapy 2. Consider need pharmacotherapy

Continuous follow-up and monitoring

32

GLOSSARY Abstinence. Smokers who remain smoking free at follow-up of at least 6 months after quitting date. Bupropion SR (bupropion sustained-release). A non-nicotine aid to smoking cessation originally developed and marketed as an antidepressant. It is chemically unrelated to tricyclics, tetracyclics, selective serotonin re-uptake inhibitors, or other known antidepressant medications. Its mechanism of action is presumed to be mediated through its capacity to block the re-uptake of dopamine and norepinephrine centrally. Clinician. A professional directly providing health care services. Extra-treatment social support component. Interventions or elements of an intervention wherein patients are provided with tools or assistance in obtaining social support outside of treatment. This category is distinct from intra-treatment social support, in which social support is delivered directly by treatment staff. First-line pharmacotherapy for tobacco dependence. First-line pharmacotherapies have been found to be safe and effective for tobacco dependence treatment and have been approved by the FDA for this use. First-line medications have established empirical record of efficacy, and should be considered first as part of tobacco dependence treatment except in cases of contraindications. Higher intensity counselling. Refers to interventions that involve extended contact between clinicians and patients. It was coded based on the length of contact between clinicians and patients (greater than 10 minutes). If that information was unavailable, it was coded based on the content of the contact between clinicians and patients. Intra-treatment social support. Refers to an intervention component that is intended to provide encouragement, a sense of concern, and interested empathic listening as part of the treatment. Low-intensity counselling. Low-intensity counselling refers to interventions that involve contact between clinicians and patients and that last between 3 and 10 minutes. If the information on length of contact was unavailable, it was coded based on the description of content of the clinical intervention. (not found but should be kept?) Minimal counselling. Minimal counselling refers to interventions that involve very brief contact between clinicians and patients. It was coded based on the length of contact between clinicians and patients (3 minutes or less). If that information was unavailable, it was coded based on the content of the clinical intervention. (not found either!) Motivation. A type of intervention designed to bolster patients resolve to quit through manipulations such as setting a quit date, use of a contract with a specified quit date, reinforcing correspondence (letters mailed from clinical/study staff congratulating the patient on his or her decision to quit or on early success), providing information about the health risks of smoking, and so on. Self-explanatory?

33

Nicotine replacement therapy (NRT). Refers to a medication containing nicotine that is intended to promote smoking cessation. There are a few nicotine replacement therapy delivery systems currently approved for use in Malaysia. These include nicotine chewing gum, nicotine inhaler and nicotine patch, nicotine nasal spray Person-to-person intervention. In-person, or face-to-face, contact between a clinician and a patient(s) for the purpose of tobacco use intervention or assessment. Practical counselling(problem solving/skills training). Refers to a tobacco use treatment in which tobacco users are trained to identify and cope with events or problems that increase the likelihood of their tobacco use. For example, quitters might be trained to anticipate stressful events and to use coping skills such as distraction or deep breathing to cope with an urge to smoke. Related and similar interventions are coping skill training, relapse prevention, and stress management. Primary care clinician. A clinician (e.g., in medicine, nursing, psychology, pharmacology, dentistry/oral health, physical, occupational, and respiratory therapy) who provides basic health care services for problems other than tobacco use per se. Primary care providers are encouraged to identify tobacco users and to intervene, regardless of whether tobacco use is the patients presenting problem. Proactive telephone counselling. Treatment initiated by a clinician who telephones and counsels the patient over the telephone. Psychosocial interventions. Refers to intervention strategies that are designed to increase tobacco abstinence rates due to psychological or social support mechanisms. These interventions comprise such treatment strategies as counselling, self-help, and behavioural treatment like rapid smoking and contingency contracting. Quit day. The day of a given cessation attempt during which a patient tries to abstain totally from tobacco use. Also refers to a motivational intervention, whereby a patient commits to quit tobacco use on a specified day. Randomised controlled trial. For the purposes of this guideline, a study in which subjects are assigned to conditions on the basis of chance, and where at least one of the conditions is a control or comparison condition. Second-hand smoke is a combination of side-stream cigarette smoke and the exhaled main-stream smoke. Those who are exposed to second hand smoke for 15 minutes in two days within a week is defined as second-hand smokers. Second-line pharmacotherapy for tobacco dependence. Second-line medications are pharmacotherapies for which there is evidence of efficacy for treating tobacco dependence, but they have a more limited role than first-line medications because: (1) the FDA has not approved them for a tobacco dependence treatment indication, and (2) there are more concerns about potential side effects than exist with first-line medications. Second-line treatments should be considered for use on a case-by-case basis after firstline treatments have been used or considered. Self-help. An intervention strategy in which the patient uses a non-pharmacologic physical aid to achieve abstinence from tobacco. Self-help strategies typically involve little contact

34

with a clinician, although some strategies (e.g., hotline/helpline) involve patient-initiated contact. Examples of types of self -help materials include: pamphlets/booklets/mailings/manuals; videos; audios; referrals to 12-step programs; mass media community-level interventions; lists of community programs; reactive telephone hotlines/helplines; and computer programs/Internet. Smokeless tobacco. Any used form of unburned tobacco, including chewing tobacco and snuff. Specialized assessments. Refers to assessment of patient characteristics, such as nicotine dependence and motivation for quitting, that may allow clinicians to tailor interventions to the needs of the individual patient. Weight/diet/nutrition component. An intervention strategy designed to address weight gain or concerns about weight gain. Interventions that teach diet/weight management strategies, incorporate weekly weight monitoring (for reasons other than routine data collection), require or suggest energy intake maintenance/reduction, and/or convey nutritional information/counselling.

35

APPENDIX 1 Modified Fagerstrm Test for Nicotine Dependence

1. How soon after you wake up do you smoke your first cigarette? Within 5 minutes (3 points) 5 to 30 minutes (2 points) 31 to 60 minutes (1 point) After 60 minutes (0 points) 2. Do you find it difficult not to smoke in places where you shouldnt, such as in church or school, in a movie, at the library, on a bus, in court or in a hospital? Yes (1 point) No (0 points) 3. Which cigarette would you most hate to give up;which cigarette do you treasure the most? The first one in the morning (1 point) Any other one (0 points) 4. How many cigarettes do you smoke each day? 10 or fewer (0 points) 11 to 20 (1 point) 21 to 30 (2 points) 31 or more (3 points) 5. Do you smoke more during the first few hours after waking up than during the rest of the day? Yes (1 point) No (0 points) 6. Do you still smoke if you are so sick that you are in bed most of the day, or if you have a cold or the flu and have trouble breathing? Yes (1 point) No (0 points)

Scoring: 7 to 10 points = highly dependent; 4 to 6 points = moderately dependent; less than 4 points =minimally dependent. Modified Fagerstrm test for evaluating intensity of physical dependence on nicotine.Adapted permission from Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrm KO. The Fagerstrm test for nicotine dependence: a revision of the Fagerstrm Tolerance Questionnaire. Br J Addict 1991;86:1119-27. (PERMISSION NOT YET GRANTED)

36

APPENDIX 2 FDA Pregnancy Class

Category A

Description Medicines are considered safe to be used throughout pregnancy. Medicines have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the foetus.

Medicines which have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human foetus. Studies in animals have not shown evidence of an increased occurrence of fetal damage, or are inadequate or may be lacking, but available data show no evidence of an increased occurrence of fetal damage, or there are evidence of an increased occurrence of fetal damage, but the significance of which is considered uncertain in humans.

Medicines which have caused or may be suspected of causing harmful effects on the human foetus or newborn infant without causing malformations. These effects may be reversible. Medicines must only be given only if the potential benefits justify the potential risk to the foetus.

Medicines that have caused, are suspected to have caused or may be expected to cause an increased incidence of human fetal malformations or irreversible damage. The use is warranted only in life-threatening situation or for a serious disease for which safer medicines cannot be used or ineffective.

Medicines which have such a high risk of causing permanent damage to the foetus that they should not be used in pregnancy or when there is a possibility of pregnancy.

37

APPENDIX 3 Nicotine gum chewing technique

Adapted with permission from .(NEW)

38

LIST OF CONTRIBUTORS

1 2 3 4 5 6 7

Dr. Prema Rajendra Dr. Ooi Choo Huck Dr. Shahidah Hashim Dr. Norfadzillah Hassan Dr. Francis Low Chee Chan Assoc. Prof. Lekrej Rampal Professor Dr. Hashimi Bohari Dr. Mohd. Rizal Hj. Manap Dr. Lee Lai Kah Dr. Adinegara Lutfi Dr. Rusilawati Mr. Abdul Malek Abdul Aziz Dr. Norinah Mustapha Dr. Mohd. Akmal Dahaman Dr. Tengku M. Izam Dr. Lee Fatt Soon Dr. Syed Azhar Syed Sulaiman Dr. Mohazmi Mohamed Mr. Leow Yeow Ming Dr. K.T. Singam Matron Dayang Abang Narudin Dr. Mohamad Nizam Jemoin Mr. Manimaran Krishnan Mr. Chandran Kanniah Mr. Chua Poh Soon Mr. Mohd. Salleh Daud Mr. Munshi Abdullah

Selangor Health Department, Ministry of Health Sarawak Health Department, Ministry of Health Kedah Health Department, Ministry of Health International Islamic University University of Malaya University Putra Malaysia University Malaysia Sarawak National University of Malaysia International Medical University Malacca-Manipal Medical College Medical Department, Ministry of Health Pharmacy Division, Ministry of Health Dental Division, Ministry of Health Department of Aboriginal Affairs Otolaryngologist, Ministry of Health Geriatrician, Hospital Klang, Ministry of Health University of Science Malaysia Academy of Medicine of Malaysia Malaysian Pharmaceutical Society Academy of Family Physician Nursing Board, Ministry of Health Health Department, Ministry of Health Health Department, Ministry of Health Hospital Ipoh, Ministry of Health Johore Health Department, Ministry of Health Medical Assistant Board, Ministry of Health Penang Hospital, Ministry of Health

8
9 10 11 12 13 14

15
16 17 18 19 20 21 22 23 24 25 26 27

39