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Nicotine Pharmacology & Principles of Addiction module
Drug Interactions with Smoking module
Assisting Patients with Quitting module
Hands-on workshop
Aids for Cessation module
Tobacco trigger tapes
Case scenarios
EPIDEMIOLOGY of TOBACCO USE is the chief, single,
avoidable cause of death in our society and the most
important public health issue of our time.”
C. Everett Koop, M.D., former U.S. Surgeon General
“CIGARETTE SMOKING…
Mackay & Erickson. (2002). The Tobacco Atlas. World Health Organization.
WORLDWIDE ADULT TOBACCO USE PREVALENCE (Men/Women)
Canada25.0 (27.0/23.0)
USA20.9 (23.9/18.1)
UK26.5
(27.0/26.0)
Australia19.5 (21.1/18.0)
China35.6 (66.9/4.2)
Russian Federation36.5 (63.2/9.7)
Japan33.1 (52.8/13.4)
India16.0 (29.4/2.5)Brazil
33.8 (38.2/29.3)Namibia
50.0 (65.0/35.0)
South Africa26.5 (42.0/11.0)
Sweden19.0 (19.0/19.0)
Yugoslavia47.0 (52.0/42.0)
Iran15.3 (27.2/3.4)
Guinea51.7 (59.5/43.8)
New Zealand25.0 (25.0/25.0)
Philippines32.4 (53.8/11.0)
France34.5 (38.6/30.3)
TRENDS in ADULT CIGARETTE CONSUMPTION—U.S., 1900–2005
Annual adult per capita cigarette consumption and major smoking and health events
Centers for Disease Control and Prevention. (1999). MMWR 48:986–993.Per-capita updates from U.S. Department of Agriculture, provided by the American Cancer Society.
Adapted from NCI Smoking and Tobacco Control Monograph 8, 1997, p. 13. Data from U.S. Department of Agriculture. Reprinted with permission. Thun et al. 2002. Oncogene 21:7307–7325.
ADULT PER-CAPITA CONSUMPTION of TOBACCO, 1880–2005
All forms of
tobacco are
harmful.
Year
TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2005
Trends in cigarette current smoking among persons aged 18 or older
Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2005 NHIS. Estimates since 1992 include some-day smoking.
Other effects: cataract, osteoporosis, periodontitis, poor surgical outcomes
U.S. Department of Health and Human Services. (2004). The Health Consequences of Smoking: A Report of the Surgeon General.
USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General.
There is no safe level of second-hand
smoke.
Second-hand smoke causes premature death and disease in nonsmokers (children and adults)Children:
Increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma
2006 REPORT of the SURGEON GENERAL: INVOLUNTARY EXPOSURE to TOBACCO SMOKE
Respiratory symptoms and slowed lung growth if parents smokeAdults:
Immediate adverse effects on cardiovascular systemIncreased risk for coronary heart disease and lung cancer
Millions of Americans are exposed to smoke in their homes/workplacesIndoor spaces: eliminating smoking fully protects nonsmokers
Separating smoking areas, cleaning the air, and ventilation are ineffective
SMOKE-FREE WORKPLACE LAWS
Smoke-free offices, restaurants, and bars: California, Colorado, Connecticut, Delaware, Hawaii, Maine, Massachusetts, New Jersey, New York, Rhode Island, Vermont, Washington
Smoke-free offices and restaurants: Arkansas, District of Columbia (bars in 2007), Florida, Georgia, Idaho, Louisiana, Montana (bars in 2009), Nevada, North Dakota, Utah (bars in 2009)
Smoke-free offices: Maryland, South DakotaData current as of November 9, 2006.
QUITTING: HEALTH BENEFITS
Lung cilia regain normal functionAbility to clear lungs of mucus increasesCoughing, fatigue, shortness of breath decrease
Excess risk of CHD decreases to half that of a
continuing smokerRisk of stroke is reduced to that of people who have never smoked
Lung cancer death rate drops to half that of a
continuing smokerRisk of cancer of mouth,
throat, esophagus, bladder, kidney, pancreas
decrease
Risk of CHD is similar to that of people who have never smoked
Cigarettes and other forms of tobacco are addicting.
Nicotine is the drug in tobacco that causes addiction.
The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine.
U.S. Department of Health and Human Services. (1988). The Health Consequences of Smoking: Nicotine Addiction. A Report of the Surgeon General.
Nicotiana tabacumNatural liquid alkaloid
Colorless, volatile base pKa = 8.0
N
CH3N
H
Pyridine ring
Pyrrolidine ring
CHEMISTRY of NICOTINE
PHARMACOLOGY
Effects of the body on the drugAbsorptionDistributionMetabolism Excretion
Effects of the drug on the body
Pharmacokinetics
Pharmacodynamics
NICOTINE ABSORPTION
Absorption is pH dependentIn acidic media
Ionized ⇒ poorly absorbed across membranesIn alkaline media
Nonionized ⇒ well absorbed across membranesAt physiologic pH (7.3–7.5), ~31% of nicotine is unionized
At physiologic pH,nicotine is readily absorbed.
NICOTINE ABSORPTION: BUCCAL (ORAL) MUCOSAThe pH inside the mouth is 7.0.
Acidic media(limited absorption)
Cigarettes
Alkaline media(significant absorption)
Pipes, cigars,spit tobacco,
oral nicotine products
Beverages can alter pH, affect absorption.
NICOTINE ABSORPTION: SKIN and GASTROINTESTINAL TRACT
Nicotine is readily absorbed through intact skin.
Nicotine is well absorbed in the small intestine but has low bioavailability (30%) due to first-pass hepatic metabolism.
NICOTINE PHARMACOLOGY and ADDICTION: SUMMARY (cont’d)
Nicotine dependence is a form of chronic brain disease.
Tobacco use is a complex disorder involving the interplay of the following:
Pharmacology of nicotine (pharmacokinetics and pharmacodynamics)
Environmental factors
Physiologic factors
Treatment of tobacco use and dependence requires a multifaceted treatment approach.
DRUG INTERACTIONS with SMOKING
Drugs that may have a decreased effect due to induction of CYP1A2:
CaffeineFluvoxamineOlanzapineTacrineTheophylline
Absorption of inhaled insulin is 2- to 5-fold higher in smokers than in nonsmokers
Use is contraindicated in current smokers and patients who quit less < 6 months prior to treatment
PHARMACOKINETIC DRUG INTERACTIONS with SMOKING
HANDOUTSmoking cessation will reverse these effects.
PHARMACODYNAMIC DRUG INTERACTIONS with SMOKING
Smokers who use combined hormonal contraceptives have an increased risk of serious cardiovascular adverse effects:
StrokeMyocardial infarctionThromboembolism
This interaction does not decrease the efficacy of hormonal contraceptives.
Women who are 35 years of age or older AND smoke at least 15 cigarettes per day are at significantly elevated risk.
DRUG INTERACTIONS with SMOKING: SUMMARY
Clinicians should be aware of their patients’smoking status:
Clinically significant interactions result not from nicotine butfrom the combustion products of tobacco smoke.
These tobacco smoke constituents (e.g., polycyclic aromatic hydrocarbons; PAHs) may enhance the metabolism of other drugs, resulting in a reduced pharmacologic response.
Smoking might adversely affect the clinical response to the treatment of a wide variety of conditions.
Sponsored by the Agency for Healthcare Research and Quality of the U.S. Public Heath Service with
Centers for Disease Control and PreventionNational Cancer InstituteNational Institute for Drug AddictionNational Heart, Lung, & Blood InstituteRobert Wood Johnson Foundation
www.surgeongeneral.gov/tobacco/
CLINICAL PRACTICE GUIDELINE for TREATING TOBACCO USE and DEPENDENCE
EFFECTS of CLINICIAN INTERVENTIONS
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline.Rockville, MD: USDHHS, PHS.
0
10
20
30
No clinician Self-helpmaterial
Nonphysicianclinician
Physicianclinician
Type of Clinician
Esti
mat
ed a
bsti
nenc
e at
5+
mon
ths
1.0 1.1(0.9,1.3)
1.7(1.3,2.1)
2.2(1.5,3.2)
n = 29 studies
Compared to smokers who receive no assistance from a clinician, smokers who receive such assistance are 1.7–2.2 times as likely to quit successfully for 5 or more months.
Tobacco users expect to be encouraged to quit by health professionals.
Screening for tobacco use and providing tobacco cessation counseling are positively associated with patient satisfaction (Barzilai et al., 2001).
Barzilai et al. (2001). Prev Med 33:595–599.
Failure to address tobacco use tacitly implies that quitting is not important.
The CLINICIAN’s ROLE in PROMOTING CESSATION
ASK
ADVISE
ASSESS
ASSIST
ARRANGE
The 5 A’s
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline.Rockville, MD: USDHHS, PHS.
HANDOUT
The 5 A’s (cont’d)
Ask about tobacco use
“Do you ever smoke or use any type of tobacco?”
“I take time to ask all of my patients about tobacco use—because it’s important.”
“Medication X often is used for conditions linked with or caused by smoking. Do you, or does someone in your household smoke?”
“Condition X often is caused or worsened by smoking. Do you, or does someone in your household smoke?”
ASK
The 5 A’s (cont’d)
tobacco users to quit (clear, strong, personalized, sensitive)
“It’s important that you quit as soon as possible, and I can help you.”
“I realize that quitting is difficult. It is the most important thing you can do to protect your health now and in the future. I have training to help my patients quit, and when you are ready, I will work with you to design a specialized treatment plan.”
For most patients, quitting is a cyclical process, and their readiness to quit (or stay quit) will change over time.
Assess readiness to quit (or to stay quit) at each patient
contact.
ASSESSING READINESS to QUIT (cont’d) IS a PATIENT READY to QUIT?
Does the patient now use tobacco?
Is the patient now ready to quit?
Provide treatmentThe 5 A’s
Promote motivation
Yes
YesNo
Did the patient once use tobacco?
Prevent relapse*
Encourage continued abstinence
Yes
No
No
*Relapse prevention interventions not necessary if patient has not used tobacco for many years and is not at risk for re-initiation.
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline.Rockville, MD: USDHHS, PHS.
STAGE 1: Not ready to quit
Not thinking about quitting in the next monthSome patients are aware of the need to quit.Patients struggle with ambivalence about change.Patients are not ready to change, yet.Pros of continued tobacco use outweigh the cons.
GOAL: Start thinking about quitting.
ASSESSING READINESS to QUIT (cont’d)
STAGE 1: NOT READY to QUITCounseling Strategies
DON’TsPersuade
“Cheerlead”
Tell patient how bad tobacco is, in a judgmental manner
Provide a treatment plan
DOsStrongly advise to quit
Provide information
Ask noninvasive questions; identify reasons for tobacco use
“Envelope”
Raise awareness of health consequences/concerns
Demonstrate empathy, foster communication
Leave decision up to patient
The 5 R’s—Methods for increasing motivation:
Relevance
Risks
Rewards
Roadblocks
Repetition
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline.Rockville, MD: USDHHS, PHS.
Tailored, motivational messages
STAGE 1: NOT READY to QUITCounseling Strategies (cont’d)
STAGE 1: NOT READY to QUITA Demonstration
CASE SCENARIO:MS. STEWART
You are a clinician providing care to Ms. Stewart, a 55-year-old patient with emphysema.
She uses two different inhalers to treat her emphysema.
STRESS MANAGEMENT SUGGESTIONS:Deep breathing, shifting focus, taking a break.
Smokers confuse the relief of withdrawal with the feeling of relaxation.
STAGE 2: READY to QUITDiscuss Key Issues (cont’d)
THE FACTS
Stress-Related Tobacco Use
Patients who receive social support and encouragement are more successful in quitting.
ADVISE PATIENTS TO DO THE FOLLOWING: Ask family, friends, and coworkers for support, for example, not to smoke around them and not to leave cigarettes out
Talk with their health care provider
Get individual, group, or telephone counseling
STAGE 2: READY to QUITDiscuss Key Issues (cont’d)
Social Support for Quitting
HERMAN ® is reprinted with permission from LaughingStock Licensing Inc., Ottawa, Canada
All rights reserved.
Most smokers gain fewer than 10 pounds, but there is a wide range.
Discourage strict dieting while quittingRecommend physical activityEncourage healthful diet, planning of meals, and inclusion of fruitsSuggest increasing water intake or chewing sugarless gumRecommend selection of nonfood rewards
Maintain patient on pharmacotherapy shown to delay weight gain
Refer patient to specialist or program
STAGE 2: READY to QUITDiscuss Key Issues (cont’d)
Concerns about Weight Gain
Most pass within 2–4 weeks after quitting
Cravings can last longer, up to several months or years
Often can be ameliorated with cognitive or behavioral coping strategies
Refer to Withdrawal Symptoms Information Sheet
Symptom, cause, duration, relief
Most symptoms peak 24–48 hours after quitting and
subside within 2–4 weeks.
HANDOUT
STAGE 2: READY to QUITDiscuss Key Issues (cont’d)
Concerns about Withdrawal Symptoms Discuss methods for quittingDiscuss pros and cons of available methodsPharmacotherapy: a treatment, not a crutch!Importance of behavioral counseling
Set a quit date
Recommend Tobacco Use LogHelps patients to understand when and why they use tobaccoIdentifies activities or situations that trigger tobacco useCan be used to develop coping strategies to overcome the temptation to use tobacco
Each time any form of tobacco is used, log the following information:
Time of day
Activity or situation during use
“Importance” rating (scale of 1–3)
Review log to identify situational triggers for tobacco use; develop patient-specific coping strategies
STAGE 2: READY to QUITFacilitate Quitting Process (cont’d)
Tobacco Use Log: Instructions for useDiscuss coping strategies
Cognitive coping strategiesFocus on retraining the way a patient thinks
Behavioral coping strategies
Involve specific actions to reduce risk for relapse
STAGE 2: READY to QUITFacilitate Quitting Process (cont’d)
HANDOUT
Review commitment to quit
Distractive thinking
Positive self-talk
Relaxation through imagery
Mental rehearsal and visualization
Cognitive Coping Strategies
STAGE 2: READY to QUITFacilitate Quitting Process (cont’d)
Thinking about cigarettes doesn’t mean you have to smoke one:
“Just because you think about something doesn’t mean you have to do it!”Tell yourself, “It’s just a thought,” or “I am in control.”Say the word “STOP!” out loud, or visualize a stop sign.
When you have a craving, remind yourself:“The urge for tobacco will only go away if I don’t use it.”
As soon as you get up in the morning, look in the mirror and say to yourself:
“I am proud that I made it through another day without tobacco.”
Cognitive Coping Strategies: Examples
STAGE 2: READY to QUITFacilitate Quitting Process (cont’d)
Control your environmentTobacco-free home and workplace
Remove cues to tobacco use; actively avoid trigger situations
Modify behaviors that you associate with tobacco: when, what, where, how, with whom
Substitutes for smokingWater, sugar-free chewing gum or hard candies (oral substitutes)
Take a walk, diaphragmatic breathing, self-massage
Actively work to reduce stress, obtain social support, and alleviate withdrawal symptoms
Behavioral Coping Strategies
STAGE 2: READY to QUITFacilitate Quitting Process (cont’d)
Provide medication counselingPromote complianceDiscuss proper use, with demonstration
Discuss concept of “slip” versus relapse“Let a slip slide.”
Offer to assist throughout quit attemptFollow-up contact #1: first week after quittingFollow-up contact #2: in the first monthAdditional follow-up contacts as needed
Congratulate the patient!
STAGE 2: READY to QUITFacilitate Quitting Process (cont’d)
Actively trying to quit for goodPatients have quit using tobacco sometime in the past 6 months and are taking steps to increase their success.
Withdrawal symptoms occur.
Patients are at risk for relapse.
STAGE 3: Recent quitter
GOAL: Remain tobacco-free for at least 6 months.
ASSESSING READINESS to QUIT (cont’d)
STAGE 3: RECENT QUITTERSEvaluate the Quit Attempt
Status of attemptAsk about social supportIdentify ongoing temptations and triggers for relapse(negative affect, smokers, eating, alcohol, cravings, stress)Encourage healthy behaviors to replace tobacco use
Slips and relapseHas the patient used tobacco at all—even a puff?
Medication compliance, plans for terminationIs the regimen being followed?Are withdrawal symptoms being alleviated?How and when should pharmacotherapy be terminated?
Congratulate success!Encourage continued abstinence
Discuss benefits of quitting, problems encountered, successes achieved, and potential barriers to continued abstinenceAsk about strong or prolonged withdrawal symptoms (change dose, combine or extend use of medications)
Promote smoke-free environments
Social supportDiscuss ongoing sources of supportSchedule additional follow-up as needed; refer to support groups
STAGE 3: RECENT QUITTERSFacilitate Quitting Process
Relapse Prevention
Tobacco-free for 6 monthsPatients remain vulnerable to relapse.
Ongoing relapse prevention is needed.
STAGE 4: Former tobacco user
GOAL: Remain tobacco-free for life.
ASSESSING READINESS to QUIT (cont’d)
STAGE 4: FORMER TOBACCO USERS
Assess status of quit attempt
Slips and relapse
Medication compliance, plans for terminationHas pharmacotherapy been terminated?
Continue to offer tips for relapse prevention
Encourage healthy behaviors
Congratulate continued success
Continue to assist throughout the quit attempt.
READINESS to QUIT: A REVIEW
Recent quitterNot ready to quit Former tobacco user
Routinely identify tobacco users (ASK)Strongly ADVISE patients to quitASSESS readiness to quit at each contactTailor intervention messages (ASSIST)
Be a good listenerMinimal intervention in absence of time for more intensive intervention
ARRANGE follow-upUse the referral process, if needed
COMPREHENSIVE COUNSELING: SUMMARY
Brief interventions have been shown to be effective
In the absence of time or expertise:
Ask, advise, and refer to other resources, such as local programs or the toll-free quitline1-800-QUIT-NOW
BRIEF COUNSELING: ASK, ADVISE, REFER
This brief intervention can be achieved in 30 seconds.
WHAT IF…
a patient asks you about your use of tobacco?
The RESPONSIBILITY of HEALTH PROFESSIONALS
It is inconsistent
to provide health care and
—at the same time—
remain silent (or inactive)
about a major health risk.TOBACCO CESSATION
is an important component ofTHERAPY.
DR. GRO HARLEM BRUNTLAND, FORMER DIRECTOR-GENERAL of the WHO:
“If we do not act decisively, a hundred years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked.”
USDHHS. (2001). Women and Smoking: A Report of the Surgeon General. Washington, DC: PHS.
Who is a candidate for scheduled gradual reduction?
Anyone who wants to quit smokingParticularly useful in persons for whom medications might not be a first-line choice, such as pregnant women or teensSpit tobacco users (18.4% abstinent after 1 year)
Ordering informationwww.quitkey.com or 1-800-543-3744 ($59.95)
PHARMACOTHERAPY
“All patients attempting to quit should be encouraged to use effective pharmacotherapies for smoking cessation except in the presence of special
circumstances.”
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.
PHARMACOLOGIC METHODS: FIRST-LINE THERAPIES
Three general classes of FDA-approved drugs for smoking cessation:
After patch removal, skin may appear red for 24 hours
If skin stays red more than 4 days or if it swells or a rash appears, contact health care provider—do not apply new patch
Local skin reactions (redness, burning, itching)Usually caused by adhesiveUp to 50% of patients experience this reactionFewer than 5% of patients discontinue therapyAvoid use in patients with dermatologic conditions (e.g., psoriasis, eczema, atopic dermatitis)
TRANSDERMAL NICOTINE PATCH: SUMMARY
DISADVANTAGESPatients cannot titrate the dose.
Allergic reactions to the adhesive may occur.
Patients with dermatologic conditions should not use the patch.
ADVANTAGES
The patch provides consistent nicotine levels.
The patch is easy to use and conceal.
Fewer compliance issues are associated with patch use.
NICOTINE NASAL SPRAYNicotrol NS (Pfizer)
Aqueous solution of nicotine in a 10-ml spray bottleEach metered dose actuation delivers
50 µl spray0.5 mg nicotine
~100 doses/bottleRapid absorption across nasal mucosa
NICOTINE NASAL SPRAY:DOSING & ADMINISTRATION
One dose = 1 mg nicotine (2 sprays, one 0.5 mg spray in each nostril)
Start with 1–2 doses per hour
Increase prn to maximum dosage of 5 doses per hour or 40 mg (80 sprays; ~½ bottle) daily
For best results, patients should use at least 8 doses daily for the first 6–8 weeks
Termination:
Gradual tapering over an additional 4–6 weeks
NICOTINE NASAL SPRAY: DIRECTIONS for USE
Press in circles on sides of bottle and pull to remove cap
NICOTINE NASAL SPRAY: DIRECTIONS for USE (cont’d)
Prime the pump (before first use)
Obtain facial tissue or paper towelHold bottle and press on bottom with thumbPump into tissue until fine spray is observed (6–8 times)
If pump is not used for 24 hours, prime the pump 1–2 times
Tilt head back slightly and insert tip of bottle into nostril as far as comfortable
Breathe through mouth, and spray once in each nostril
Do not sniff or inhale while spraying
NICOTINE NASAL SPRAY:DIRECTIONS for USE (cont’d)
If nose runs, gently sniff to keep nasal spray in nose
Wait 2–3 minutes before blowing nose
Wait 5 minutes before driving or operating heavy machinery (spray may cause tearing, coughing, and sneezing)
Avoid contact with skin, eyes, and mouth
If contact occurs, rinse with water immediately
Nicotine is absorbed through skin and mucous membranes
NICOTINE NASAL SPRAY:ADDITIONAL PATIENT EDUCATION
What to expect (first week):Hot peppery feeling in back of throat or noseSneezingCoughingWatery eyesRunny nose
Side effects should lessen over a few daysRegular use during the first week will help in development of tolerance to the irritant effects of the spray
If side effects do not decrease after a week, contact health care provider
NICOTINE NASAL SPRAY:SUMMARY
DISADVANTAGESNasal/throat irritation may be bothersome.Nasal spray has higher dependence potential.Patients with chronic nasal disorders or severe reactive airway disease should not use the spray.
ADVANTAGESPatients can easily titrate therapy to rapidly manage withdrawal symptoms.
NICOTINE INHALERNicotrol Inhaler (Pfizer)
Nicotine inhalation system consists of
MouthpieceCartridge with porous plug containing 10 mg nicotine
Delivers 4 mg nicotine vapor, absorbed across buccal mucosa
May satisfy hand-to-mouth ritual of smoking
NICOTINE INHALER: DOSING
Start with 6 cartridges/day
Increase prn to maximum of 16 cartridges/day
Use for minimum of 3 weeks, maximum of 12 weeks
Gradual dosage reduction: if needed over additional 6–12 weeks
LONG-TERM (≥6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS
0
5
10
15
20
25
30
Nicotine gum Nicotinepatch
Nicotinelozenge
Nicotinenasal spray
Nicotineinhaler
Bupropion Varenicline
Active drugPlacebo
Data adapted from Silagy et al. (2004). Cochrane Database Syst Rev; Hughes et al., (2004). Cochrane Database Syst Rev.; Gonzales et al., (2006). JAMA and Jorenby et al., (2006). JAMA
Allows for acute dose titration as needed for withdrawal symptoms
Bupropion SR + NRT
The safety and efficacy of combination of varenicline with NRT or bupropion has not been established.
Reserve for patients unable to quit using monotherapy.
COMPLIANCE IS KEY to QUITTING
Promote compliance with prescribed regimens.
Use according to dosing schedule, NOT as needed.
Consider telling the patient:“When you use a cessation product it is important to read all the directions thoroughly before using the product. The products work best in alleviating withdrawal symptoms when used correctly, and according to the recommended dosing schedule.”