Rx for CHANGE ClinicianAssisted Tobacco Cessation TRAINING OVERVIEW
Rx for CHANGE Clinician-Assisted Tobacco Cessation
TRAINING OVERVIEW n Epidemiology of Tobacco Use module Forms of Tobacco module Nicotine Pharmacology & Principles of Addiction module Drug Interactions with Smoking module Assisting Patients with Quitting module n Hands-on workshop n n n Aids for Cessation module n Tobacco trigger tapes n Case scenarios
EPIDEMIOLOGY of TOBACCO USE
“CIGARETTE SMOKING… 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
WORLDWIDE ADULT TOBACCO USE PREVALENCE (Men/Women) Canada 25. 0 (27. 0/23. 0) France Sweden Yugoslavia 34. 5 (38. 6/30. 3) 19. 0 (19. 0/19. 0) 47. 0 (52. 0/42. 0) Russian Federation 36. 5 (63. 2/9. 7) UK China 26. 5 35. 6 (66. 9/4. 2) (27. 0/26. 0) USA Japan 20. 9 (23. 9/18. 1) 33. 1 (52. 8/13. 4) Philippines 32. 4 (53. 8/11. 0) Guinea 51. 7 (59. 5/43. 8) Iran 15. 3 (27. 2/3. 4) India 16. 0 (29. 4/2. 5) Brazil 33. 8 (38. 2/29. 3) Australia Namibia 19. 5 (21. 1/18. 0) 50. 0 (65. 0/35. 0) South Africa 26. 5 (42. 0/11. 0) New Zealand 25. 0 (25. 0/25. 0) Mackay & Erickson. (2002). The Tobacco Atlas. World Health Organization.
TRENDS in ADULT CIGARETTE CONSUMPTION—U. S. , 1900– 2005 Annual adult per capita cigarette consumption and major smoking and health events Number of cigarettes 1964 Surgeon General’s Report Broadcast ad ban End of WW II U. S. entry into WW I Master Settlement Agreement; California first state to enact ban on smoking in bars Marketing of filtered cigarettes Nonsmokers’ rights movement begins First modern reports linking smoking and cancer Great Depression Cigarette price drop Federal cigarette tax doubles 20 states have > $1 pack tax Year 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.
ADULT PER-CAPITA CONSUMPTION of TOBACCO, 1880– 2005 All forms of tobacco are harmful. Year 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.
TRENDS in ADULT SMOKING, by SEX—U. S. , 1955– 2005 Trends in cigarette current smoking among persons aged 18 or older 20. 9% of adults are current smokers Percent Male 23. 9% Female 18. 1% Year 70% want to quit Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965– 2005 NHIS. Estimates since 1992 include some-day smoking.
STATE-SPECIFIC PREVALENCE of SMOKING among ADULTS, 2005 Illinois 19. 9% California 15. 2% Kentucky 28. 7% Nevada 23. 1% Utah 11. 5% New York 20. 5% Texas 20. 0% Indiana 27. 3% Florida 21. 6% Centers for Disease Control and Prevention. (2006). MMWR 55: 1148– 1151.
PREVALENCE of ADULT SMOKING, by RACE/ETHNICITY—U. S. , 2005 32. 0% American Indian/Alaska Native* 21. 9% White* 21. 5% Black* 16. 2% Hispanic 13. 3% Asian* * non-Hispanic. Centers for Disease Control and Prevention. (2006). MMWR 55: 1145– 1148.
PREVALENCE of ADULT SMOKING, by EDUCATION—U. S. , 2005 25. 5% No high school diploma 43. 2% GED diploma 24. 6% High school graduate 22. 5% Some college 10. 7% Undergraduate degree 7. 1% Graduate degree Centers for Disease Control and Prevention. (2006). MMWR 55: 1145– 1148.
TRENDS in TEEN SMOKING, by ETHNICITY—U. S. , 1977– 2006 Trends in cigarette smoking among 12 th graders: 30 -day prevalence of use Percent White Hispanic Black Institute for Social Research, University of Michigan, Monitoring the Future Project www. monitoringthefuture. org
PUBLIC HEALTH versus “BIG TOBACCO” The biggest opponent to tobacco control efforts is the tobacco industry itself. In the U. S. , for every $1 spent on tobacco prevention, the tobacco industry spends $28 to market its products.
The TOBACCO INDUSTRY n n For decades, the tobacco industry has publicly denied the addictive nature of nicotine and the negative health effects of tobacco. April 14, 1994: Seven top executives of major tobacco companies state, under oath, that they believe nicotine is not addictive. n n n Tobacco industry documents suggest otherwise Documents available at http: //legacy. library. ucsf. edu The cigarette is a heavily engineered product. n Designed and marketed to maximize bioavailability of nicotine and addictive potential n Profits over people
An EFFECTIVE MARKETING STRATEGY: “LIGHT” CIGARETTES The difference between Marlboro and Marlboro Lights… an extra row of ventilation holes Image courtesy of Mayo Clinic Nicotine Dependence Center - Research Program / Dr. Richard D. Hurt The Marlboro and Marlboro Lights logos are registered trademarks of Philip Morris USA.
TOBACCO INDUSTRY ADVERTISING $15. 15 billion spent in the U. S. in 2003 n 21. 5% increase over 2002 figures n 35. 0% increase over 2001 figures Billions of dollars spent n Year Federal Trade Commission. (2005). Cigarette Report for 2003.
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ANNUAL U. S. DEATHS ATTRIBUTABLE to SMOKING, 1997– 2001 Percentage of all smokingattributable deaths* Cardiovascular diseases Lung cancer Respiratory diseases Second-hand smoke* 137, 979 123, 836 101, 454 38, 112 Cancers other than lung Other 34, 693 1, 828 32% 28% 23% 9% 8% <1% TOTAL: 437, 902 deaths annually * In 2005, it was estimated that nearly 50, 000 persons died due to second-hand smoke exposure. Centers for Disease Control and Prevention. (2005). MMWR 54: 625– 628.
ANNUAL SMOKING-ATTRIBUTABLE ECONOMIC COSTS—U. S. , 1995– 1999 Prescription drugs, $6. 4 billion Medical expenditures (1998) Ambulatory care, $27. 2 billion Hospital care, $17. 1 billion Other care, $5. 4 billion Nursing home, $19. 4 billion Societal costs: $7. 18 per pack Annual lost productivity costs (1995– 1999) Men, $55. 4 billion Women, $26. 5 billion Billions of dollars Centers for Disease Control and Prevention. (2002). MMWR 51: 300– 303.
COMPOUNDS in TOBACCO SMOKE An estimated 4, 800 compounds in tobacco smoke, including 11 proven human carcinogens Gases n n n Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde Particles n n n Nicotine Nitrosamines Lead Cadmium Polonium-210 Nicotine does NOT cause the ill health effects of tobacco.
2004 REPORT of the SURGEON GENERAL: HEALTH CONSEQUENCES OF SMOKING FOUR MAJOR CONCLUSIONS: n n Smoking harms nearly every organ of the body, causing many diseases and reducing the health of smokers in general. Quitting smoking has immediate as well as long-term benefits, reducing risks for diseases caused by smoking and improving health in general. Smoking cigarettes with lower machine-measured yields of tar and nicotine provides no clear benefit to health. The list of diseases caused by smoking has been expanded. U. S. Department of Health and Human Services. (2004). The Health Consequences of Smoking: A Report of the Surgeon General.
HEALTH CONSEQUENCES of SMOKING n Cancers n n n Acute myeloid leukemia Bladder and kidney Cervical Esophageal Gastric Laryngeal Lung Oral cavity and pharyngeal Pancreatic n n n Acute (e. g. , pneumonia) Chronic (e. g. , COPD) n n n Abdominal aortic aneurysm Coronary heart disease Cerebrovascular disease Peripheral arterial disease Reproductive effects n Pulmonary diseases n Cardiovascular diseases Reduced fertility in women Poor pregnancy outcomes (e. g. , low birth weight, preterm delivery) Infant mortality 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.
HERMAN ® is reprinted with permission from Laughing. Stock Licensing Inc. , Ottawa, Canada All rights reserved.
2006 REPORT of the SURGEON GENERAL: INVOLUNTARY EXPOSURE to TOBACCO SMOKE n n Second-hand smoke causes premature death and disease in nonsmokers (children and adults) Children: n n n There is no safe level of second-hand smoke. Increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma Respiratory symptoms and slowed lung growth if parents smoke Adults: n Immediate adverse effects on cardiovascular system n Increased risk for coronary heart disease and lung cancer n Millions of Americans are exposed to smoke in their homes/workplaces n Indoor spaces: eliminating smoking fully protects nonsmokers n Separating smoking areas, cleaning the air, and ventilation are ineffective USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General.
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 Dakota Data current as of November 9, 2006.
QUITTING: HEALTH BENEFITS Time Since Quit Date Circulation improves, walking becomes easier Lung function increases up to 30% Excess risk of CHD decreases to half that of a continuing smoker Lung cancer death rate drops to half that of a continuing smoker Risk of cancer of mouth, throat, esophagus, bladder, kidney, pancreas decrease Lung cilia regain normal function 2 weeks to 3 months 1 to 9 months Ability to clear lungs of mucus increases Coughing, fatigue, shortness of breath decrease 1 year 5 years Risk of stroke is reduced to that of people who have never smoked after 15 years Risk of CHD is similar to that of people who have never smoked 10 years
BENEFICIAL EFFECTS of QUITTING: PULMONARY EFFECTS FEV 1 (% of value at age 25) AT ANY AGE, there are benefits of quitting. Never smoked or not susceptible to smoke 100 75 Stopped smoking at 45 (mild COPD) Smoked regularly and susceptible to effects of smoke 50 Disability 25 Stopped smoking at 65 (severe COPD) Death 0 25 50 75 Age (years) COPD = chronic obstructive pulmonary disease Reprinted with permission. Fletcher & Peto. (1977). BMJ 1(6077): 1645– 1648.
Cumulative risk (%) Reduction in cumulative risk of death from lung cancer in men Age in years Reprinted with permission. Peto et al. (2000). BMJ 321(7257): 323– 329.
SMOKING CESSATION: REDUCED RISK of DEATH n On average, cigarette smokers die approximately 10 years younger than do nonsmokers. Years of life gained n Prospective study of 34, 439 male British doctors Mortality was monitored for 50 years (1951– 2001) Among those who continue smoking, at least half will die due to a tobacco -related disease. Age at cessation (years) Doll et al. (2004). BMJ 328(7455): 1519– 1527.
FINANCIAL IMPACT of SMOKING Buying cigarettes every day for 50 years @ $4. 26 per pack Money banked monthly, earning 1. 5% interest $342, 729 $228, 486 Packs per day $114, 243 0 100 200 300 Hundreds of thousands of dollars lost 400
EPIDEMIOLOGY of TOBACCO USE: SUMMARY n n n About one in five adults are current smokers; smoking prevalence varies by sociodemographic characteristics. Nearly half a million U. S. deaths are attributable to smoking annually. Smoking costs the U. S. $157. 7 billion per year. Lifetime financial costs of smoking can exceed $300, 000 for a heavy smoker. At any age, there are benefits to quitting smoking. The biggest opponent to tobacco control efforts is the tobacco industry itself.
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