??a??p? ?ap??s

1
??a??p? ?ap??sµat?? se e?d???? ?µ?de? ?ap??st??

• ???e???? F?????
• ??e?µ????????
• ?at?e?? ??a??p?? ?ap??sµat??
• ???e??de?? Te?ape?t????
• ??????? S???? ??????S?????? ?T??O?

2
??d???? ?µ?de? ?ap??st??

• ?s?e?e?? µe a?ap?e?st??? ??s?µata
• ?s?e?e?? µe ?a?d?a??e?a?? ??s?µata
• ?s?e?e?? µe ????at???? ??s?µata
• St?? e???µ?s???

3
The Problem of COPD
1990
2010
1. Ischaemic heart disease
1. Ischaemic heart disease
2. Cerebrovascular disease
2. Cerebrovascular disease
3. Lung cancer
3. Lung cancer
4. Pneumonia
4. COPD
5. COPD
5. Pneumonia
6. Colon and rectum cancers
6. Colon and rectum cancers
7. Stomach cancer
7. Stomach cancer
8. Breast Cancer
8. Cirrhosis of the liver
9. Road traffic accidents
9. Breast cancer
10. Cirrhosis of the liver
10. Road traffic accidents
ERS/ELF. European Lung White Book 2003
4
The Problem of COPD
1990
2010
1. Ischaemic heart disease
1. Ischaemic heart disease
2. Cerebrovascular disease
2. Cerebrovascular disease
3. Lung cancer
3. Lung cancer
4. Pneumonia
4. COPD
5. Stomach cancer
5. Stomach cancer
6. Road traffic accidents
6. Road traffic accidents
7. Self-inflicted injuries
7. Pneumonia
8. COPD
8. Colon and rectum cancers
9. Colon and rectum cancers
9. Self-inflicted injuries
10. Cirrhosis of the liver
10. Cirrhosis of the liver
ERS/ELF. European Lung White Book 2003
5
??a??p? ?ap??sµat?? se as?e?e?? µe ??ap?e?st???
??s?µata

• ??e??e?? ?ate????t???e? ?d???e? ??a t?? d?a??p?
  t?? ?ap??sµat??
• US Agency for Health Care Policy (1996, 2000,2008
  update)
• ACCP 2002
• ERS 1995,2007
• American psychiatric Association 1996

6
ERS Task Force ERJ 2007
7
??a??p? ?ap??sµat?? se as?e?e?? µe ??ap?e?st???
??s?µata

• S?s??t?s? ?ap??sµat?? µe a?ap?e?st??? ??s?µata
• S?s?et??eta? a?t???????? µe t?? ??? ?a? t??
  ?a????? t?? p?e?µ??a
• ?p??e??e? t?? ??e??? t?? ?s?µat?? (s?ßa??te?a
  s?µpt?µata, s????te?e? pa?????se??)
• S?µß???e? st?? a??pt??? sp????? pa??se??
• ( ?st????tt?s? ?, ???e??? a1 a?t?????????)
• ?p??e??e? t?? eµf???s? ?a? t?? ?a? t?? e??????
  t?? p?e?µ???a? ?a? t?? p?e?µ?????? f?µat??s??
• S?µß???e? st?? p???µ?te?? ?a? ta??te?? ??pt?s?
  t?? a?ap?e?st???? ?e?t?????a?
• ERS TASK FORCE
• Eur Respir J 2007

8
?as??? S?µe?a

• ? d?a??p? t?? ?ap??sµat?? p??pe? ?a ?e??e?ta?
  a?ap?spast? µ???? t?? a?t?µet?p?s?? t??
  a?ap?e?st???? as?e???
• ??t? pe???aµß??e?
• ?a?t??? e?t?µ?s? t?? ep?p?d?? ?ap??sµat??
  ???s?µ?p????ta? a?t??e?µe????? µe??d??? ?p?? t?
  e?p?e?µe?? CO
• Fa?µa?e?t??? a???? ??a t?? a?t?µet?p?s? t??
  e???t?s?? st?? ????t???, ? ?p??a pe???aµß??e?
• --ß??p??p???? ?/?a?
• -- ?p??at?stata ????t???? ? s??d?asµ?
  d?af??et???? µ??f?? ?p??atast?t?? ????t????
• -- ßa?e???????

9
?as??? S?µe?a

• St??? ?ap??st?? p?? de? e??a? ????t?p???µ???? ?a
  d?a?????? t? ??p??sµa ?a p??pe? p??te??eta?
  t??????st?? µe??s? µe t?? ß???e?a t?? NRT ?? µ?a
  ?d?? p??? t?? te???? d?a??p? t?? ?ap??sµat??
• ?? ?ap??st?? p?? de? e?d?af????ta? ??a µe??s? ?
  d?a??p? t?? ?ap??sµat?? ?a p??pe? ?a ?aµß?????
  a?t?st???? s?µß???? ap? t?? ??at??, ?a? ?
  s?µß???? a?t? ?a p??pe? ?a epa?a?aµß??eta? se
  ???e ep?µe?? ep?s?e??

10
??t?µ?s? as?e??? µe a?ap?e?st??? ??s?µata se
s??s? µe t?? d?a??p? t?? ?ap??sµat??

• ?p?ped? ?ap??sµat?? (smoking status)
• ????t??
• ????t?s? ( ß????µ???? de??te?, Fagerström Test
  for Nicotine Dependence(FTND)
• Sp???µ?t??s? ( e?t?µ?s? p?e?µ?????? ?e?t?????a?,
• p???µ? a????e?s? ?e?t???????? d?ata?a???)
• ?p?f?a?? ????? ?????? ß??a ? d?sp???a e??a?
  s???? S???? ?p?d?????s? ap? t??? as?e?e?? a???
  ?a? ap? t? s?st?µa ??e?a?
• ???G?? G?? ?G????? ???G?OS?

11
(No Transcript)
12
(No Transcript)
13
??a??p? ?ap??sµat????ap?e?st??? ?e?t?????a
Never smoked or not susceptible to smoke
100 75 50 25 0
Smoked regularly and susceptible to its effects
Stopped at 45
FEV1 ( of value at age 25)
Disability
Stopped at 65
Death
25
50
75
Age (years)
Adapted from Fletcher et al, Br Med J 1977.
14
?a?a?t???st??? ?ap??st?? µe a?ap?e?st???
p??ß??µata

• ??s????? p????sµ??
• (????????? s?s??t?s? a?ap?e?st???? s?µpt?µ?t??
  µe t? ??p??sµa, p????? f???? s?µß????? ??a
  d?a??p?, te???? a???? st?? s?µß????? ??a
  d?a??p?)
• S??-??s???t?te?
• S???? s???pa??? ??? ?a? ????? a?ap?e?st????
  p??ß??µ?t?? µe ?at??????, a???de?? d?ata?a???
  (s?et????ta? µe a???µ??? p??a??t?ta ap?t???a? t??
  d?a??p??)
• ????t?s?
• S?ßa??te?? e???t?s? (?????te?? ßa?µ?????a st??
  ???µa?a FTND, ?????te?e? t?µ?? e?p?e?µe??? CO)
• ???p?? e?sp???? t?? ?ap???
• ?? ?ap??st?? µe ??? e?sp????? ta??te?a ?a?
  ßa??te?a t?? ?ap??
• ??e???? s?µat???? ß?????
• S???? ep???µ?t? se ??p?ßa?e?? as?e?e?? µe ??? ?
  ?a????? t?? p?e?µ??a
• S?????? a???s? ß????? 4-5 kg

15
?a?????te? p?? s?et????ta? µe t?? d?a??p? t??
?ap??sµat??
Heart
Males
Females
Lung
Heart
Other
Success rate ()
Lung
Other
Age in years
JAMA1998
16
???s????s? a?ap?e?st???? as?e??? ??a d?a??p?
?ap??sµat??

• ?????aµµat?sµ?? ?µe??µ???a? d?a??p??
• ?????aµµat?sµ?? s????? ep?s???e??, t??????st?? 8
  ?ste ?a e??s???e? t? ap?t??esµa(1,2,4,8,12
  eßd?µ?de?, 6?? ?a? 12?? µ??a?)
• ?????????? ?p?st?????
• Fa?µa?e?t??? ?e?ape?a
• ? s??d?asµ?? fa?µa?e?t???? ?e?ape?a? ?a?
  ??????????? ?p?st??????- t??p?p???s?? t??
  s?µpe??f???? ap?te???? t?? p??te???µe??
  a?t?µet?p?s? p??t?? ??aµµ?? se ??e? t?? d?e??e??
  ?ate????t???e? ?d???e? ??a t?? d?a??p? t??
  ?ap??sµat?? se ????? t??? ?ap??st?? µe
  a?ap?e?st??? ??s?µata.

17
???s????s? a?ap?e?st???? as?e???

• ?????????? pa??µßas?-S?µß???e?t??? Te?ape?a
• ?t?µ??? (individual counselling)
• - ap?dede??µ??? ap?te?esµat???t?ta(evidence level
  A)
• ?µad???(group counselling )
• -e?µ???s? te?????? s?µpe??f???? ?a?
  a??????p?st????? µeta?? t?? µe??? t?? ?µ?da?.
• -ap?te?esµat???, ?d??? ?ta? s??d???eta? µe
  fa?µa?e?t??? ?e?ape?a.
• ?e? e??a? ???st? a? ??e? µ????te?? ? µe?a??te??
  ap?te?esµat???t?ta ap? t?? at?µ??? ?e?ape?a
• ???ef?????
• proactive? t??ef????? ?p?st????? t?? ?ap??st?
  ?ste ?a ap?pe??a?e? d?a???e? t? ??p??sµa
• reactive? t??ef?????? ??aµµ??
  ep????????a?/ß???e?a? st?? ?p??e? ape??????ta? ??
  ?ap??st??.
• ?e? fa??eta? ?a a????e? t?? ap?te?esµat???t?ta
  t?? fa?µa?e?t???? ?e?ape?a? ? t?? at?µ????
  ?e?ape?a?.

18
??a??p? Kap??sµat?? ?a? ???-Fa?µa?e?t??? Te?ape?a
COMPREHENSIVE REVIEW Review of bupropion for
smoking cessation ROBYN RICHMOND1 NICHOLAS
ZWAR2 Drug and Alcohol Review (June 2003), 22,
203 220
REVIEW ARTICLE Benefits and Risks of
Pharmacological Smoking Cessation Therapies in
Chronic Obstructive Pulmonary Disease Edwin J.
Wagena, Maurice P.A. Zeegers, Constant P. van
Schayck1 and Emiel F.M. Wouters Drug Safety 2003
26 (6) 381-403
19
Fa?µa?e?t??? ?e?ape?a ?a? d?a??p? ?ap??sµat?? se
a?ap?e?st????? as?e?e??

• ?) ?p??at?stata ????t????(NRT)
• Te?ape?a p??t?? ??aµµ?? ??a t?? d?a??p? t??
  ?ap??sµat?? se ?ap??st?? gt10 ts??????/24???
• Cochrane µeta-a????s? 105 t??a??p???µ???? µe?et??
  µe NRT
• odds ratio 1.8 ?p?? t?? NRTs vs e??????? f??µa??
  
• µe t? ß???e?a t?? ?p??atast?t?? pa?at??e?ta?
  a???s? t?? ap???? ap? t? ??p??sµa st??? 6-12
  µ??e? ?at? 7 ?a? t? p?s?st? a?t? a????eta?
  pe?a?t??? ?at? 7-8 a? p??ste?e? ?a? ?e?ape?a
  s?µpe??f????.
• St?? ??a ????? ? ap??? ap? t? ??p??sµa ?ta? 17
  ??a t?? ?µ?da t?? NRT se s??s? µe t? 10 st??
  ?µ?da e??????.
• ????µ? ?p?t??p?--gts???? st?? µe??te? µe NRTs.
  ?p?te?e? ??de??? p?? ? p??sp??e?a d?a??p?? ??e?
  p????? p??a??t?te? ?a ap?t??e?.
• Cohrane Database Syst Rev 2004

20
Fa?µa?e?t??? ?e?ape?a ?a? d?a??p? ?ap??sµat?? se
a?ap?e?st????? as?e?e??-?e??te?
ap?te?esµat???t?ta? NRTs

• A) 446 ?ap??st?? µe ??? a???????sa? p????aµµa
  d?a??p?? ?aµß????ta? 4 d?af??et???? µ??f?? NRTs
  ( ep?s???e?? st?? 2? ?a? 6? eßd?µ?da st???
  3,6,9,12 µ??e?)
  
• ?p??? ap? t? ??p??sµa st??? 12 µ??e?
• 1.8st?? ?µ?da µe t? a?t??????t? t?? 5 mg,
• 8.7 µe t? a?t??????t? t?? 15 mg,
• 5.1 ??a t?? ?µ?da µe t?? e?sp?e?st??a ????t????,
  
• 3.5 µe t?? s??d?asµ? e?sp?e?st??a ?a?
  a?t??????t?? t?? 15 mg
• ? s??????? ep?t???a ?ta?
• Tonnesen et al Eur Respir J 200016717-722

5,6
21
Fa?µa?e?t??? ?e?ape?a ?a? d?a??p? ?ap??sµat?? se
a?ap?e?st????? as?e?e??-?e??te?
ap?te?esµat???t?ta? NRTs

• B) 370 ?ap??st?? µe ???.??aßa? ?e?ape?a µe
  ?p????ss?a d?s??a t?? 2mg ? e??????? f??µa?? ?
  µ???? ?p?st????? (4 ep?s???e??, 6 t??ef???µata) ?
  µe???? ?p?st????? (7 ep?s???e??, 5 t??ef??????
  ep????????e?).
• Tonnesen et al Chest 2006130314-316
• ?e?a??te?a p?s?st? ep?t???a? st?? ?µ?da t?? NRTs
  
• -23 vs 10 e??????? f??µa?? st??? 6 µ??e?.
• -S?µa?t??? ße?t??s? st?? ßa?µ?????a st? SGRQ se
  ?s??? d?????a? t? ??p??sµa se s??s? µe t???
  ?ap??st??
• (-10.9 vs -2.9)

22
Fa?µa?e?t??? ?e?ape?a ?a? d?a??p? ?ap??sµat?? se
a?ap?e?st????? as?e?e??-?e??te?
ap?te?esµat???t?ta? NRTs

• G) Lung Health study
• ?????? e?tat??? p????aµµa d?a??p?? µe ???s?
  ts???a? ????t???? ?e?ape?a s?µpe??f???? ?a?
  st?? s????e?a pa?a???????s? a?? 4µ??e? ??a 5
  ?????a ??a ap?f??? t?? ?p?t??p??.
• ? ap??? ap? t? ??p??sµa ?ta? ?????te?? st??
  ?µ?da pa??µßas?? ( 35 st?? 1? ????? ?a? 22
  µet? 5 ?????a vs 10 ?a? 5).
• Anthonisen et al JAMA 1994

23
Lung Health Study? d?a??p? t?? ?ap??sµat??
µe??se t?? ???µ? ??pt?s?? t?? FEV1
Mean changes in FEV1 in continuing smokers and
sustained quitters
Scanlon et al. Am J Respir Crit Care Med 2000
24
Fa?µa?e?t??? ?e?ape?a ?a? d?a??p? ?ap??sµat?? se
a?ap?e?st????? as?e?e??

• ?) ???p??p???? pa?atetaµ???? ap?d?sµe?s??
• 1.?eta-a????s? 19 µe?et?? ? OR 2.06 ?pe?
  ß??p??p????? vs e???????? fa?µ???? Richmond R,
  Zwar N,Drug and Alcohol review 2003
• 2.Taskin et al Lancet 2001
• 404 as?e?e?? µe ?p?a-µ?t??a ???,?ap??st?? 28
  ts??????/24???, FTND 7,
• ? pa?atetaµ??? ap??? ap? t? ??p??sµa ?ta?
  s?µa?t??? ?????te?? sta ?t?µa p?? ??aßa?
  ß??p??p???? se s??s? µe t?? ?µ?da t?? e????????
  fa?µ????
• eßd?µ?de? 4-7, 28 vs 16, plt 0.003
• eßd?µ?de? 4-12, 18 vs 10
• eßd?µ?de? 4-26, 16 vs 9
• -Point prevalence quit rates ( 6 µ??e?)?
  s?µa?t??? ????te?e? st?? ?µ?da t?? ß??p??p?????
  se s??s? µe t? e??????? f??µa?? (23 vs 16)
• -?? f??µa?? e??a? asfa??? ??a t?? ??????s? se
  ?t?µa µe ???

25
?p?te??sµata d?a??p?? st?? ??? µe t? ???s?
ß??p??p?????
?a?atetaµ??? ap??? (eßd?µ?de? 47)
of participants
BUP SR
PBO
COPD study
Taskin et al Lancet 2001
p?0.05 versus PBO
26
Fa?µa?e?t??? ?e?ape?a ?a? d?a??p? ?ap??sµat?? se
a?ap?e?st????? as?e?e?? G) ?a?e???????

• ?e??t? se as?e?e?? µe ??? stad??? ?-??? ?at? GOLD
• ? ap?te?esµat???t?ta t?? ßa?e???????? ?ta?
  a?????? µe a?t? st?? ?e???? p????sµ?
• ? ap?te?esµat???t?ta ?ta? ?????te?? se as?e?e??
  µe ?p?a-µ?t??a ???, pa?? t?? ?pa??? ?s????te???
  e???t?s??
• (µe?a??te??? a???µ?? ts??????/?µ??a, µe?a??te??
  d????e?a ?ap??st???? s????e?a?, ?FTND).
• ?? p?? s????? pa?e????e?e? st? ?µ?da t??
  ßa?e???????? ?ta?
• ?a?t?a, ?µet??, pa???e?a ??e??a, a?p??a,
  µete???sµ??, ???µ??e?? a??te??? a?ap?e?st????.
• ? s????t?ta t?? pa?e?e??e??? ?ta? a?????? µe a?t?
  p?? pa?at??????e st?? ?e???? p????sµ?

Tashkin et al, Chest Mar 2011
27
???s? t?? ßa?e???????? st?? ???
S??e??? ap??? ap? t? ??p??sµa st?? 12 ?a? 52
eßd?µ?de?
OR 8.40
Plt0.0001
OR 4.05
OR 4.88
plt0.0001
42.3
Plt0.0001
25.8
18.6
8.8
7.2
5.6
Tashkin et al, Chest Mar 2011
28

• ?µpe???a ?at?e??? d?a??p?? ?ap??sµat?? se
  as?e?e?? µe
• a?ap?e?st??? ??s?µata
• 298 ?ap??st?? µe a?ap?e?st??? ??s?µata
• 175 ??? (11 p??t?d?a???s?e?sa)
• 123 ?s?µa

29
??a??p? ?ap??sµat?? se ?t?µa µe a?ap?e?st???
??s?µata
Control Respiratory
F??? ?51,5- G 48,5 ? 48,5- G 51,5
?????a 45,8 10,5 48,9 11,4
?a??ta/?t? 44 27 51 35
????µ?? ts??????/?µ??a 33,4 14,6 34,8 15,6
?e??t?? Fagerström 7,1 1,9 7,05 1,8
DSM IV 13,5 7,5 14,5 7,4
30
??a??p? ?ap??sµat?? se ?t?µa µe a?ap?e?st???
??s?µata
?????????? ???????G??
1? ???S???? ????? ???G??? ??? ?ST??
FEV1 94 71 92
FVC 101 86 103
FEV1/FVC 78 65 76
FEF 25-75 74 38 65
12 ????S
FEV1 93 74 93
FVC 101 89 101
FEV1/FVC 77 66 77
FEF 25-75 69 40 69
31
S??e??? ?p??? ap? t? ??p??sµa se ?t?µa µe ??? ?a?
?s?µa
S????? ?ap??st?? µe ??ap?e?st??? ??s?µata µe ??a
ta ?e?ape?t??? s??µata
32
S??e??? ?p??? ap? t? ??p??sµa se ?t?µa µe ??? ?a?
?s?µa
??af???? st?? ep?t???a a?????a µe t? ?e?ape?t???
s??µa st? s????? t?? a?ap?e?st???? as?e???
33
S??e??? ?p??? ap? t? ??p??sµa se ?t?µa µe ???
34
??a??p? ?ap??sµat?? ?a?d?a??e?a?? ??s?µata
35
??a??p? ?ap??sµat?? ?a?d?a??e?a?? ??s?µata

• ? ?a?d?a??e?a?? ??s??(CVD) e??a? ? s????te??
  a?t?a ?a??t?? st?? p????µ??e? ???e?
• ?? ??p??sµa s?et??eta? µe t?? a??pt???
• ????? stefa??a??? s??d??µ??
• ??f??d??? ?a??t??, ?a?d????????? a?t??????a?
• ?e??fe????? a??e?a??? ??s??
• ???e?a??? ???efa????? epe?s?d???

36
??a??p? ?ap??sµat?? ?a?d?a??e?a?? ??s?µata

• ? s???????? ???d???? CVD e??a? d?p??s??? st???
  ?ap??st??
• Stefa??a?a ??s?? (RR1.7-5.8)
• ?s?a?µ??? ??? (RR1.5-3.0)
• ??µ???a???? ??? (RR10.3)

37
??p??sµa ?a? ???t?t?ta ap? stefa??a?a ??s?
??s?e?a?t?µe?? !!!!
Relative Risk (95 CI)a
1-14/Day
15-24/Day
?25/Day
Nonsmokers
Cigarettes/DayCurrent Smokers
a The probability of an event (developing a
disease) occurring in exposed people compared
with the probability of the event in nonexposed
people. Adjusted for age.Willett et al. N Engl J
Med. 1987317(21)1303-1309.
38
??p??sµa ?a? ?a?d?a??e?a?? S?st?µa
Nicotine Sympathetic nervous
system BP, HR ? Myocardial contractility Vasoco
nstriction

• Carbon Monoxide
• CO Hb ?
• Tissue Hypoxia
• Myocardial Hypoxia
• Myocardial Ischemia
• Acute myocardial
• infarction
• Sudden death

• Benzopyrene
• Glycoprotein
• Plateletes
• Fibrinogen
• Homocysteine
• Oxygen radicals
• Endothelial destruction
• ?therogenesis
• Hypertension
• Peripheral Vascular Disease
• Ischemic stroke

39
??a??p? ?ap??sµat?? ?a?d?a??e?a?? ??s?µata

• ?et? t?? d?a??p? ? ???d???? CVD µe???eta? st?
  µ?s? se 2 pe??p?? ?????a
• ??e?????ta? 10-20 ?????a ??a ?a ft?se? ?
  ?ap??st?? st?? s?et??? ???d??? t?? µ? ?ap??st?
  ??a ?a?d?a??e?a?? ??s?

40
??a??p? ?ap??sµat?? ?a?d?a??e?a?? ??s?µata

• ?? pe??ss?te??? as?e?e?? µe CVD s??e?????? ?a
  ?ap?????? µet? t? e??t???? ap? t? ??s???µe?? ?
  ?p?t??p?????? ( 30 µet? ap? ??? !!!)
• ??asta?t???? pa?????te? st?? d?a??p?
• (a) f?ß?? a???s?? t?? s?µat???? ß?????
• (ß) s?µa?t???? ßa?µ?? e???t?s??
• (?) ????s? s?s??t?s?? t?? ?a?d?????????
  p??ß??µat?? ?a? µe t? ??p??sµa

41
??a??p? ?ap??sµat?? ?a?d?a??e?a?? ??s?µata

• ??t?µet?p?s?
• S??t?µ? s?µß???? ? µ???? ep?d?as? st???
  ?a?d?a??e?a???? as?e?e??
• ??????µµata e?tat???? pa?a???????s?? ? a???????
  t?? p??a??t?ta d?a??p?? ?at? 80
• ?a p?????µµata p??pe? ?a pe???aµß?????
• ?????????? ?p?st?????
• Fa?µa?e?t??? a????

42
??a??p? ?ap??sµat?? - ?a?d?a??e?a?? ??s?µata

• Fa?µa?e?t??? a????
• S?????? ?e????µe µet? t?? p??te? d?? eßd?µ?de?
  ap? t? ??? epe?s?d??
• ?p?t??p??ta? ?a? ?? t?e?? ????e? ?e?ape?e? p??t??
  ??aµµ?? (?p??at?stata ????t????, ß??p??p????,
  ßa?e???????)
• ???s??? st?? a????ep?d??se?? ( p.?. ß??p??p????
  µp??e? ?a ep??e?se? t?? µetaß???sµ? t??
  ß-a?ast?????, ta a?t?a?µ?peta??a?? µp??e? ?a
  µetaß?????? t?? µetat??p? t?? ß??p??p????? st???
  e?e????? µetaß???te? t??)

43
??a??p? ?ap??sµat?? - ?a?d?a??e?a?? ??s?µata

• ?a ?p??at?stata ????t???? e??a? asfa?? st??
  sta?e?? ?a?d?a??e?a?? ??s?
• ?e? a??????? t?? s?ßa??t?ta t?? ?a?d?a??e?a???
  ??s??
• ???pe? ?a s??ta????af???ta? aµ?s?? µet? ap? t??
  ???d? ap? t?? ??T ( se ???)
• ?e? ?p???e? s?s??t?s? µeta?? t?? ???s??
  a?t??????t?? ????t???? ?a? ?a?d?a??e?a???
  s?µßaµ?t??
• Nicotine Replacement Therapy and Cardiovascular
  Disease, Ford CL, Zlabek JA,
• Mayo Clin Procn2005 May 80(5)652-6

44
???s? ???p??p????? se ?a?d?a??e?a??
??s?µata??p?as???e? t?? p??a??t?te? d?a??p?? se
s??s? µe t? e??????? f??µa??
?a?atetaµ??? ap??? (eßd?µ?de? 47)
of participants
BUP SR
PBO
Cardiovascular study
Tonstand et al.2001
45
???s? ?a?e???????? sta ?a?d?a??e?a?? ??s?µata
46
??a??p? ?ap??sµat?? ?a?d?a??e?a?? ??s?µata

• ?a?e???????
• ap?te?esµat??? ?a? asfa??? f??µa?? ??a t??
  d?a??p? t?? ?ap??sµat?? se ?a?d?a??e?a????
  as?e?e?? se s??s? µe t? e???????
• Riggoti et al, Circulation 2010

47
?a?e??????? se ?a?d?a??e?a???? as?e?e??S?ed?asµ?
?
F?s? ?e?ape?a?
F?s? µ? ??????s?? ?e?ape?a?
?a?e??????? 1mg d?? ?µe??s???
N703
???????? F??µa??
?ßd.
9
1
12
52
?p?s?e??a?????? e?t?µ?s??
??a??????a??p???s?
?µe??µ???a-St???? d?a??p??
?e???d?? ?e?ape?a? ?a?a???????s? ??e? ?e?ape?a?
B W W W W W W W W W W W WL 1 2 3 4 5 6 7 8 9 10 11 12 W W W W W W W W W W W W 13 14 16 20 24 28 32 36 40 44 48 52
C C C C C C C C C C C C C C T C T C T C T C T C C
48
???????S????
??s?st? s??e???? ap???? 12 eßd?µ?d?? µe
ßa?e??????? st??? ?a?d?a??e?a???? as?e?e??
47.0
?a?e??????? ??a?t? ????????? Fa?µ???? OR 6.11
(95 CI 4.18,8.93), plt0.0001
13.9
(n355)
(n359)
Rigotti et al, Circulation 2010
49
???????S????
??s?st? s??e???? ap???? 52 eßd?µ?d?? t??
ßa?e???????? st??? ?a?d?a??e?a???? as?e?e??
?a?e??????? ??a?t? ????????? Fa?µ???? OR 3.14
(95 CI 1.93.5.11), plt0.0001
19.2
7.2
(n355)
(n359)
Rigotti et al, Circulation 2010
50
?a?e??????? se ?a?d?a??e?a???? as?e?e??
??ep???µ?te? e????e?e? (??)

• ?? p?? s????? a?ep???µ?te? e????e?e? p??
  a?af?????a? st? µe??t? ?ta? ?? e???
• S?ßa??? ?? e?d??????a? st? 6.5 (varenicline )
  ?a? t? 6.0 (placebo) as?e???
• ?aµ?a S?ßa?? ?? de? s?et???ta? µe ?at??????, t?s?
  a?t??t???a? ? µ? f?s???????? s?µpe??f???

S????te?e? AE ??d??????a? se 5 t?? s?µµete???t?? ??asd?p?te ?µ?da? ?a?e??????? (n353) ???????? F??µa?? (n350)
S????te?e? AE ??d??????a? se 5 t?? s?µµete???t?? ??asd?p?te ?µ?da? n () n ()
?a?t?a 104 (29.5) 30 (8.6)
?efa?a???a 45 (12.7) 39 (11.1)
??p??a 42 (11.9) 23 (6.6)
?µet?? 29 (8.2) 4 (1.1)
?s?????sta ??e??a 28 (7.9) 6 (1.7)

51
?a?e??????? se ?a?d?a??e?a???? as?e?e??
?e?µ????µ??a ?a?d?a??e?a?? s?µß?µata ?a? s?????
?a??t??

• ?? ?µ?de? ßa?e???????? ?a? e???????? fa?µ???? de?
  d??fe?a? sta e???
• ?a?d?a??e?a?? s?µß?µata
• 7.4 ??a?t? 6.6, d?af??? 0.8, 95 CI - 3.0,
  4.6)
• ?a?d?a??e?a??? ???at??
• 0.3 ??a?t? 0.6, d?af??? -0.3, 95 CI - 1.3,
  0.7
• T??at?? p?s?? a?t??????a?
• 0.6 ??a?t? 1.4, d?af??? -0.8, 95 CI, -2.3,
  0.6
• ????µ?? () s?µµete???t?? s?µf??a µe t?? ???s?
  t?? ep?t??p?? te?µ????s?? ?a?d?a??e?a???
  s?µßaµ?t??.

52

• ?µpe???a d?a??p?? ?ap??sµat??
• se as?e?e?? µe
• ?a?d?a??e?a?? ??s?µata

?a?e?????? S???d??? ??s?µ?t?? T??a??? 2010
53
??T???S
54
?a?a?t???st??? t?? ?ap??st??
?ap??st?? µe ?a?d?a??e?a?? ??s?µata ?ap??st?? ????? ?a?d?a??e?a?? ??s?µata
?????a 52 9,8 ?t? 45 10,3 ?t?
F??? ??d?e? G??a??e? 64,9 35,1 47,4 52,6
????µ?? ts??????/?µ??a 34,7 16 33,3 14
????µ?? pa??t??/????? 55,2 33 42,5 26
S??? ???µa?a? Fagerström 7,1 1,8 7,1 1,9
55
??s?st? ep?t???a? d?a??p??
?a?e?????? S???d??? ??s?µ?t?? T??a??? 2010
56
Fa?µa?e?t??? a????
?ap??st?? µe ?a?d?a??e?a?? ??s?µata
57
?etaß??? a?t???a??? p?es??
58
?etaß??? ß?????
week
month
59
??a??p? ?ap??sµat?? se ?t?µa µe ????at????
??s?µata?
60
??a??p? ?ap??sµat?? se as?e?e?? µe ????at????
??s?µata

• ?ap??st??? s????e?a ?a? e???t?s? ap? t?
  ??p??sµa e??a? d?sa?????a ?????te?? sta ?t?µa µe
  ????at????? d?ata?a??? se s??s? µe t?? ?e????
  p????sµ?
• ???? d?p??s?a p?s?st? ?ap??sµat?? sta ?t?µa µe
  ????at???? ??s?µata, 41 vs 22.5
• ?? ????at????? as?e?e?? ????? p??? a???µ???
  ???d??? ??a as???e?e? s?et???µe?e? µe t? ??p??sµa
  
• ?? ??p??sµa s?µß???e? p??? st?? a???µ???
  ??s???t?ta ?a? ???s?µ?t?ta p?? pa?at??e?ta? st???
  ????at?????? as?e?e??

61
??a??p? ?ap??sµat?? se as?e?e?? µe ????at????
??s?µata

• ????de?? ??ata?a???
• 25 p??a??t?ta eµf???s?? se ??? t? d????e?a t??
  ???? (???)
• ?ap??st??? s????e?a ? 31.5 ??? 54.6
• ?at??????
• 30 at?µ?? µe e?e??? ?at?????? e??a? ?ap??st??
• 60 at?µ?? µe ?st????? ?at??????? e??a? ?ap??st??
• ?? ?ap??st?? ????? d?p??s???? ???µ??? a??pt????
  ?at???????
• ?? ?ap??st?? µe s?ßa?? e???t?s? ap? t?? ????t???
  ????? 2p??s?a p??a??t?ta ?a a?apt????? ?at??????
  se s??s? µe t??? µ? ?ap??st??

62
??a??p? ?ap??sµat?? se as?e?e?? µe ????at????
??s?µata

• S????f???e?a
• ?a?at??e?ta? st? 1-1,5 t?? ?e????? p????sµ??
  (???)
• 70-85as?e??? µe s????f???e?a e??a? ?ap??st??,
  OR5.9 ?ap??sµat?? se s??s? µe t?? ?e????
  p????sµ?
• 50 e??a? ßa?e?? ?ap??st?? ( gt 25 ts????a/24???,
  ????? ßa?µ?????a st?? ???µa?a e???t?s??
  Fagerström,pe??ss?te?e? ?a? p?? ßa???? e?sp????
  a?? ts?????)
• S?ßa?? ep?peda ?ap??sµat?? s?et????ta? µe
  a???µ??a ?et??? s?µpt?µata ( p.? pa?a????µa,
  pa?a?s??se??), e?att?µ??a a???t??? s?µpt?µata
  (p.? pe?????sµ??? s??a?s??µat??? ??f?as?,
  ???s?a?? e?att?µata), a???µ??? ???s? ??s???,
  s????te?e? ??s??e?e? ??a ????at?????? ??????,
  ????te?e? e??p??aµ?d???? pa?e????e?e?, p???d???a
  ?a? a???µ??? ???d??? ??a a?t??t???a

63
References

• Wilhelm K, Wedgwood L, Niven H, Kay-Lambkin F.
  Smoking cessation and depression Current
  knowledge and future directions.Drug Alcohol Rev.
  2006 Jan25(1)97-107
• Ricotta N. Treatment of tobacco use and
  dependence. N Engl J Med 2002346(7)506-512
• Gelenberg AJ, Leon J, Evins AE, Parks JJ, Rigotti
  NA. Smoking cessation in patients with
  psychiatric disorders. Prim Care Companion J Clin
  Psychiatry 200810(1)52-58
• Tobacco use and cessation in psychiatric
  disorders National Institute of Mental Health
  Report
• Nicotine and Tobacco Research,Vol 10,Number
  12,Dec2008(1691-1715)

64
??a??p? ?ap??sµat?? se as?e?e?? µe ????at????
??s?µata

• ?? a???de?? d?ata?a??? ?a? ? ?at?????? p??pe? ?a
  d?a???st??? p??? ap? t?? ??a??? ?a? ?at? t??
  pa?a???????s?
• ??? ?ata???pt??? s?µpt?µata eµfa?????ta? ?at? t?
  d?a??p?
• ? d?a??p? t?? ?ap??sµat?? p??pe? ?a a????e? µet?
  t?? sta?e??p???s? t?? ??????? d?ata?a???

?pa?te?ta? ste?? pa?a???????s?
65
??a??p? ?ap??sµat?? se as?e?e?? µe ????at????
??s?µata

• US Department of ?ealth and Human Services
  Clinical Practice Guidelines( 2009)
• Te?ape?e? 1?? ??aµµ??
• a)?p??at?stata ????t????
• ß)ß??p??p???? pa?atetaµ???? ap?d?sµe?s??
• ?)ßa?e???????

66
??a??p? ?ap??sµat?? se as?e?e?? µe ????at????
??s?µata

• NRTs t??a??p???µ??? µe??t? µe ts???a ????t????
  vs e??????? f??µa?? se ?t?µa µe ?at?????? ?µet? 3
  µ??e? ?e?ape?a? ? ap??? ap? t? ??p??sµa ?ta?
  29.5 µe t?? ts???a ????t???? ?a? 12. µe t?
  e??????? f??µa??
• Kinnusen T et al, J Consult Clin Psychol 1996
• NRTs s????f???e?a 10 eßd?µ?de? ?e?ape?a? µe
  a?t??????t? ????t???? ?a? ??a ? d?? p?????µµata
  ?????e?ape?a? ? ?a? ??a t?? d?? ?µ?de? ? ep?t????
  d?a??p? ?ta? 35.5 st? t???? t?? ?e?ape?a? ?a?
  14 st??? 6 µ??e?. ?a ap?te??sµata e??a? d?af???
  a?????a µe t?? ????at???? a???? (?t?pa vs t?p???
  ) Am J Psychiatry 2000

67
??a??p? ?ap??sµat?? se as?e?e?? µe ????at????
??s?µata

• ???p??p???? s????f???e?a
• 53 s??????? as?e?e?? ??aßa? ß??p??p???? vs
  e??????? f??µa??? 7 ap? t??? 19 st? ?µ?da t??
  ß??p??p????? ?a? 2 ap? t??? 22 st?? ?µ?da t??
  e???????? fa?µ???? ?at?fe?a? 7 ?µ??e? ap????.
• ? ß??p??p???? s?et?st??e µe ße?t??s? st??
  µ??µ? ?a? st?? p??s???
• J Clin Psychiatry 2005

68
??a??p? ?ap??sµat?? se as?e?e?? µe ????at????
??s?µata

• ?a?e??????? ????at???? ??s?µata
• ?e??t? se s?????e? ?a??µe????? ???????? p?a?t????
• 412 as?e?e?? µe ?at??????, ????s?, d?p?????
  d?ata?a?? ??aßa? ?e?ape?a µe NRT(204) ?
  ßa?e??????? (208)
• ????a? 7 ep?s???e?? (1 ep?s?e?? a?? eßd?µ?da)
• ?p?s?e?? 3 ??a??p? ?ap??sµat??
• ? d?a??p? t?? ?ap??sµat?? e?t?µ????e st?? 7?
  ep?s?e??
• (4 eßd?µ?de? µet? t?? d?a??p?)
• Stapleton et al Addiction 2007

69
??a??p? ?ap??sµat?? se as?e?e?? µe ????at????
??s?µata

• ?a?e??????? ????at???? ??s?µata
• ?p?te??sµata
• µe?a??te?? ap?te?esµat???t?ta µe t?? ßa?e???????
  st?? 4 eßd?µ?de? se s??s? µe ta NRTs
• pa??µ??e? pa?e????e?e? (e?d??, s????t?ta) ap? t??
  ßa?e??????? st??? ????at?????? as?e?e?? se s??s?
  µe t?? ?e???? p????sµ?.
• Stapleton et al Addiction 2007

70
??a??p? ?ap??sµat?? se as?e?e?? µe ????at????
??s?µata Short term smoking cessation (4 weeks
after quit day)

72
72
61
55
Stapleton et al, Addiction 2007, 103, 146-154
71
?d?a?te?e? p??f????e?? st??? as?e?e?? µe
????at???? ??s?µata

• ?) ? ?ap??? ep??e? t?? µetaß???sµ? ??s??? µ?s?
  t?? ??t????µat?? ?450 1?2. ?e t?? d??s? t??
  ?ap??? a????eta? ? ???a?s? ?a? e?att????ta?
  s?µa?t??? ta ep?peda st? a?µa ???sµ????
  a?t?????s???? (a??pe??d???, f???fe?a????,
  ??a??ap??? ?.?)? ???s??? sta ep?peda t??
  ????at????? fa?µ???? ?ta? a??????? ?? ?ap??st????
  s????e?e?
• ?) ?? as?e?e?? µe ????at???? ??s?µata ?a p??pe?
  ?a pa?a?????????ta? ste?? ??a a??a??? st??
  d???es? ?a? st?? s?µpe??f??? , p?? µp??e? ?a
  s?et????ta? µe ta ste??t??? s?µpt?µata ap? t??
  d?a??p? t?? ?ap??sµat??

72
?d?a?te?e? p??f????e?? st??? as?e?e?? µe
????at???? ??s?µata

• G) ?t?µa µe s????f???e?a, sta ?t?µa a?t? µp?????
  a? efa?µ?st??? ?a? st?at?????? µe??s?? t??
  ?ap??sµat?? pa?? p?????? d?a??p??.
• ?) ?p???e? a?af??? ??a?s?? t?? ????s????
  s?µpt?µ?t?? se as?e?? µe s????f???e?a p??
  e??µßa?e ßa?e??????? ?a??? ?a? µa??a???
  epe?s?d??? se ?t?µ? µe d?p????? d?ata?a??. ?
  ???????? µe??te? p?? ß??s???ta? se e?????? ?a
  d?asaf???s??? ta e??t?µat??? se s??s? µe t??
  asf??e?a t?? ßa?e???????? se ????at??????
  as?e?e??.

73
Tobacco smoking status and quit rates based on
presence of psychiatric disorder
Ziedonis et al, Nic Tobacco 2008, 1691-1715
74

• ?µpe???a d?a??p?? ?ap??sµat??
• se as?e?e?? µe
• ????at???? ??s?µata

75
?a?a?t???st??? ?????sµ??

• ?p? 2027 ?ap??st?? p?? s?µµete??a? st? p????aµµa
  ,
• 512 (25) a?t?µet?p??a? ????at???? p??ß??µata
• ? µe???? p?e????f?a (60) pa???s?a?e ?at??????

76
????at????? ??ata?a???
?at?????? 59,8
????s? 5
???se?? pa????? 14,1
??at??f???? d?ata?a??? 3,3
??p?????? ??ata?a??? 2,1
????de?? d?ata?a??? 8,7
???? 3,7
S??d?asµ?? 3,3
77
?a?a?t???st??? ?????sµ??
?? ????at????? ????at?????
Mean (SD) Mean (SD) p-value
F??? M55 F45 M37 F63 lt0,001
?????a 45,9 (10,7) 47,7 (10,3) 0,002
?a??ta ?t? 44,2 (28,6) 47,6 (29,3) 0,022
?e??t?? Fagerström 7,1 (1,9) 7,3 (1,8) 0,037
DSM-IV 12,9 (7,3) 16,1 (7,9) lt0,001
78
S?µa?t???t?ta ?a? eµp?st?s??? µeta?? t?? ?µ?d??
t?? ?ap??st??
??????? eµpe???a se ?ap??st?? µe ????at????
s??-??s???t?ta
?p?ped? S?µa?t???t?ta? ?p?ped? ?µp?st?s????
?ap??st?? µe ????at???? ??s?µata 9 1.1 6 2
???e?? ?ap??st?? 9 1.3 7 2
???µa?a 1-10 ??s? ???ete ?a d?a???ete t? ??p??sµa
? ??s? p?ste?ete ?t? ?a ta ?ataf??ete?
79
S??e??? ?p??? ap? t? ??p??sµa
????at?????
?? ????at?????
80
S??e??? ap??? st? t???? t?? ?e?ape?a? se
d?af??et???? ?e?ape?t???? ?µ?de?
81
??????? eµpe???a se ?ap??st?? µe ????at????
s??-??s???t?ta
?e? pa?at??????e stat?st???? s?µa?t??? a??a??
st?? ep???µ?a, st? ?????, st?? d?s????a
s?????t??s?? ?a? st?? d?ata?a??? t?? ?p??? ?at?
t?? ?e?ape?a.
82
??????? eµpe???a se ?ap??st?? µe ????at????
s??-??s???t?ta

• ?e? pa?at??????e s?µa?t??? d?af??? st??
  ?ata???pt??? d???es?, st?? ???te????? af?p??se??,
  st?? ??µ? ?a? st?? ??e?? ?at? t? d????e?a t??
  ?e?ape?a?

83
?a?µ?????a st?? ???µa?a DSM IV ??? 1 ?t?? µet?
t?? d?a??p?
84
??????? eµpe???a se ?ap??st?? µe ????at????
s??-??s???t?ta
??ep???µ?te? e????e?e? ????at????? ?ap??st?? ???e?? ?ap??st??
Na?t?a 47.2 44
?e??e??a ??e??a 20.8 20.1
????st?µ?a 20.8 27.6
??p??a 18.9 24.6
?p????a 11.3 6.7
????µ??? ??e?? 9.4 3
??ata?a??? ?p??? 7.5 9
?efa?a???a 5.7 3.7
??s??????t?ta 5.7 10.4
85
??????? eµpe???a se ?ap??st?? µe ????at????
s??-??s???t?ta

• S??????S???? ap? t?? µe??t? µa? ? d?a??p?
  t?? ?ap??sµat?? µp??e? ?a e??a? ep?t???? µe
  asf??e?a se ?ap??st?? µe ????at???? ??s?µata ?p??
  ?a? se ???e?? ?ap??st??.

86

• S?µp??asµa
• ? d?a??p? t?? ?ap??sµat?? e??a? ef??t?
• ???pe? ?a p??te??eta? se ????? t??? as?e?e?? µe
  ?????a ??s?µata
• ??e? s?µa?t??? ep?t???a
• ?a?e????e?e? a?????e? µe t?? ?e???? p????sµ?

87
??a??p? ?ap??sµat?? ?a? e???µ?s???
88
??a??p? ?ap??sµat?? ?a? e???µ?s???

• ??aße??? ep?pt?se?? t?? ?ap??sµat??
• ???? t?? e???µ?s???
• ?e??s? t?? ????µ?t?ta? ( se ??d?e? ?a? ???a??e?)
• ?at? t?? d????e?a t?? e???µ?s????
• ????s? t?? eµß?????? ??s???t?ta? ?a?
  ???s?µ?t?ta?( p.? ? ???d???? ap??????s??
  p?a????ta ??µa??eta? ap? 1.4 4.0)
• Br Med J 2004328364

89
??a??p? ?ap??sµat?? ?a? e???µ?s???

• ??aße??? ep?pt?se?? t?? ?ap??sµat??
• ?et? t?? t??et?
• ?e??µ??? s?µat??? ß???? ?at? t?? ?????s?
• ( 200 gr ????te??)
• 40 a???µ???? ???d???? ??a ß?ef??? ??s???t?ta
• 2p??s??? ???d???? ??a s??d??µ? a?f??d???
• a?ap?e?st????, ?s?µa ?.?.
• ????µ???? ???d???? ??a p??ß??µata s?µpe??f????
  ?a? µa??s?a??? d?s????e?
• Curr Opin Pediatr 199517128-31

90
??a??p? ?ap??sµat?? ?a? e???µ?s???

• ??S?????S
• ?? f?s????????? a??a??? st?? e???µ?s??? µe??????
  t?? ????? ?µ?se?a? ???? t?? ????t???? ?a?
  a??????? t?? ep???µ?a
• ? ????????? ???t??? s???? ?d??e? t?? e?????? p??
  s??e?????? ?a ?ap?????? ?a t? ???ß???
• ?? ???a??e? p?? s??e?????? ?a ?ap?????? e??a?
  s?????? ?e?te??? ?????a?, ?aµ???te???
  ???????????????µ????, epa??e?µat???? ?a?
  µ??f?t???? ep?p?d??
• ?a te?e?ta?a 20 ?????a t? ??p??sµa ?at? t??
  e???µ?s??? ??e? µe???e? ?at? 60-75.Ost?s? t? 40
  t?? ?ap??st???? s??e?????? ?a ?ap?????? se µ????
  t?? e???µ?s???? ?a? t? 20 se ??? t? d????e?a t??
  e???µ?s????.
• Women Birth 200720161-8

91
???s????s? t?? ?ap??st??a? e?????

• ????????s? t?? ???a???? a?apa?a??????? ?????a? ?a
  d?a?????? t? ??p??sµa (e??µe??t??? ?????,
  ?at?????? s?µß???? ap? ????? t??? epa??e?µat?e?
  ??e?a?)
• ????????s? ??a d?a??p? t??????st?? st? 1?
  t??µ??? t?? ???s?? (? µe?a??te??? ???d???? ??a t?
  ?µß??? e??a? µeta?? 4?? ?a? 9?? µ??a)
• Cohrane Database Syst Rev 2004

92
Fa?µa?e?t??? ?e?ape?a ??a t?? d?a??p? t??
?ap??sµat?? st?? e???µ?s???

• S?????? p??t?µ?ta? - ?????? ??a ?????? asf??e?a?
  t?? eµß????-? d?a??p? ????? ?aµ?a a???? ( cold
  turkey)
• ??????te?? se ???a??e? µe ?????te?? µ??f?t??? ?a?
  ?????????-??????µ??? ep?ped?
• ? ß??p??p???? ?a? ? ßa?e??????? de? p??te????ta?
  
• ( de? ?p?????? µe??te? s?et??? µe t??
  ap?te?esµat???t?ta ?a? t?? asf??e?a t??? st??
  e???µ?s???)
• CNS Drugs 200721(12)983-93

93
Fa?µa?e?t??? ?e?ape?a ??a t?? d?a??p? t??
?ap??sµat?? st?? e???µ?s???-?p??at?stata
????t???? (NRTs)

• ???a? asfa???
• ? ????t??? ??e? ?e???t????? d??s? ?a? µp??e? ?a
  ep?d??se? st?? p?a????ta ?a? st? ?µß???
• ?? p??a??? ???d???? t?? fa?µa?e?t???? a????? ?a
  p??pe? ?a ????st??? se s??s? µe t?? s?????s?
  t?? d?a??p?? t?? ?ap??sµat??
• ?p?????? e?de??e?? ap? µe??te? pa?at???s?? p?? ta
  NRTs e??a? asfa??ste?a ap? t? ??p??sµa ?at? t??
  d????e?a t?? e???µ?s???? ?a? p?? de? s?et????ta?
  µe a???µ??? ???d??? ??a s?ßa?? pe???e???t???
  s?µß?µata.
• Nicotine Tob Res 2009 Nov11(11)1265-73
• J Obstet Gynaecol Can 2009Aug31(8)744-7

94
Fa?µa?e?t??? ?e?ape?a ??a t?? d?a??p? t??
?ap??sµat?? st?? e???µ?s???-?p??at?stata
????t???? (NRTs)

• ???a? ap?te?esµat????
• ? p??s???? NRTs st?? ?e?ape?a s?µpe??f????
  (CBT-congitive behavioral therapy) a???se t??
  ep?t???a t?? d?a??p?? ?at? 3 f????
• ? s?µµ??f?s? t?? e????? µe ta NRTs e??a? ?aµ???
  ?µ?? ? s?µµ??f?s? µe a?t? t?? µ??f? ?e?ape?a?
  e??a? pa?????ta? ep?t???a? t?? d?a??p??
• Nicotine Tob Res 2009 Nov11(11)1265-73
• J Obstet Gynaecol Can 2009Aug31(8)744-7

95
Fa?µa?e?t??? ?e?ape?a ??a t?? d?a??p? t??
?ap??sµat?? st?? e???µ?s???-?p??at?stata
????t???? (NRTs)

• ?? ???a??e? p?? de? µp????? ?a d?a?????? t?
  ??p??sµa ?at? t?? ???s? ????? fa?µa?e?t??? a????
  ?a µp????sa? ?a ß???????? ap? ta ?p??at?stata
  ????t????
• ?a p?????ta p?? d????? pe??stas?a?? a?a???f?s?
  (ts???e?, ?p????ss?a d?s??a, inhalers) e??a?
  p??t?µ?te?a ???? t?? µ????te??? ap????f?s?? ap?
  t? ?µß???.
• ??? ???s?µ?p??????? d?ade?µ??? a?t??????ta
  s???st??ta? ta 16???? ap?d?sµe?s?? ?ste ?a
  µe???eta? ? ap????f?s? ap? t?? p?a????ta ?a? t?
  ?µß???.
• ? fa?µa?e?t??? a???? ?a p??pe? p??ta ?a
  s???de?eta? ap? ?????????? ?p?st????? t?? e?????
  ?a? ap? te?????? t??p?p???s?? t?? s?µpe??f????.

96
???a??st?