Smoking: The Talk You’ve Never Heard Michael B. Honan, MD CardioVascular Associates, PC Brookwood Medical Center December 30, 2008 Disclosures None Objectives I want to convince you that smoking cessation is: Far and away the most impactful thing smokers can do to help their long-term health and life expectancy. “This is much more important to how long you live and how healthy you are than whether we open your artery or not.” I want you to have the information needed to give you the greatest chance of success in this endeavor. Motivation is the single biggest factor determining whether or not someone will quit smoking. Approaches to the Discussion • Be sure they know that you understand that: • This is their decision, • that your role is only to give them the information that you have that they might benefit from, and • that you will do what you can for them regardless of what they choose to do. • Your message might not resonate until the 6th or 7th time you have this conversation, but it is your role to allow them the opportunity to reconsider their decision to smoke. • They may not succeed in quitting until their 6th or 7th attempt. Public Health Service Guidelines – The 5A Model 1. Ask about smoking. 2. Advise one to quit. 3. Assess willingness to quit. 4. Assist those willing to quit. 5. Arrange for follow-up. Fiore MC, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville (MD): US Dept Health Human Svcs Public Health Svc; 2000. Also 2008 Update. Approaches to the Discussion • Help them to understand that they can quit. • There are more former than current smokers in the US. • Up to 85% of smokers after MI have quit smoking. • It’s never “too late” to quit smoking. • The older the smoker and the longer the smoking duration, the greater the chances of quitting. • Encourage them to have this conversation with themselves. • “List the reasons you want to continue to smoke, and the reasons you might not want to start back.” Individualize your discussion for each patient. Smoking and Mortality In 1928, smoking linked to lung cancer1. In 1938, smoking linked to mortality overall2. The first Surgeon General’s Report labeled smoking “the single most important source of preventable morbidity and premature mortality.” in 1964. 1. Lombard HL, Doering CR. N Engl J Med 1928;198:481-7. 2. Pearl R. Science 1938;87:216-7. Surgeon General’s Report May 2004 438,000 deaths per year- still the #1 cause of preventable death in the US. 19% of all deaths!!! Reduces lifespan of the average smoker by: 13.2 years for males 14.5 years for females 5,522,257 years of potential life lost in the US in 2001. Deaths Attributed to Smoking Heart Disease Stroke COPD Other Other Cancers Secondhand Smoke Lung Cancer Morbid Mortal Wkly Rep 2003;52:842-4. Risk Factors Unmodifiable Modifiable Age Cigarette smoking Family history of early Hypertension CAD Cholesterol-HDL, LDL, Male gender Triglycerides Genetic factors Diabetes African-American Overweight Poor diet Lack of regular exercise Cocaine/crack use Cardiovascular Risk Factors 8422 Men Age 40-64 Followed for 72,011 person-years Smoking > 1 ppd Smoking > 1 ppd Weight > 129% ideal vs < 112% Cholesterol > 268 vs < 219 Systolic BP > 150 vs < 130 Diastolic BP > 94 vs < 80 0 0.5 1 1.5 2 2.5 3 3.5 Relative Risk of Major Coronary Events There are also interactions between risk factors. The Pooling Project Research Group. J Chron Dis 1978;31:201-306. Cardiovascular Effects Impairs endothelial function – vasoconstriction. Pro-thrombotic Increases fibrinogen, hs-CRP, and homocysteine levels. Reduces anti-thrombin III. Increases platelet aggregation. Causes catecholamine release. Increases lipolysis, fatty acid release, VLDL levels. Lowers HDL cholesterol. Reduces the oxygen content of blood. Carbon monoxide binds irreversibly to hemoglobin. Impaired pulmonary function – raises A-a gradient. Bazzano LA. Ann Intern Med 2003;138:891-7. Cardiac Effects Atherosclerosis Promotes coronary plaque formation. Promotes plaque rupture/ acute coronary syndromes. Promotes premature coronary bypass closure and restenosis. Reduces coronary blood flow and promotes coronary vasospasm – cath lab demos1,2. Nicotine increases oxygen utilization and demand by increasing heart rate & BP – increases ischemia3. Arrhythmias-PVCs, APCs, atrial fib, MAT, VT, V-fib. Cardiomyopathy independent of atherosclerosis4. 1. Kaijser L, Berglund B. Clin Physiol 1985;5:541-52. 2. Maouad J, et al. Catheter Cardiovasc Diagn 1986;12:366-75. 3. Wolk R. J Amer Coll Cardiol 2005;45:910-4. 4. Hartz AJ, et al. N Engl J Med 1984;311:1201-6. Cardiovascular Effects 33.5% of smoking-related deaths1. Coronary artery disease (X 2.5)2 – angina, myocardial infarction, arrhythmias, sudden death, heart failure. Cerebrovascular disease – stroke (X 3),3 hemorrhagic stroke (X 3.29)4, and TIA. Peripheral vascular disease (X 7.3)5 – claudication, leg ulcers, impaired wound healing, gangrene, aneurysms of aorta and other vessels, venous insufficiency (X 2.4).6 Interaction with other risk factors – diabetes, lipids, hypertension, estrogen, genetics. 1. Morbid Mortal Wkly Rep 2003;52:842-4. 2. The Pooling Project Research Group. J Chron Dis 1978;31:201-306. 3. Hankey GJ. J Cardiovasc Risk 1999;6:207-11. 4. Kurth T, et al. Stroke 2003;34;2792-5. 5. Fowler B, et al. Aust NZ J Publ Health 2002;26:26:291-24. 6. Gourgo S, et al. Am J Epidemiol 2002;155:1007-15. Relative Risk Cardiovascular Ischemic Heart Disease 2.8 1.64 Other Heart Disease 1.78 1.22 Cerebrovascular Disease 3.27 1.04 Current Atherosclerosis 2.44 Former 1.33 Aortic Aneurysm 6.21 3.07 Other Arterial Disease 2.07 1.01 0 1 2 3 4 5 6 7 Relative Risk of Cardiovascular Events http://apps.nccd.cdc.gov/sammec/edit_risk_data.asp Smoking Cessation after MI Occurred in 56.2% at 6 months and 56.8% at a year among 19 hospitals in the Premier Registry. 1 Results in a 36-46% reduction in mortality.2,3 Reduction in recurrent nonfatal MI. Better control of other cardiovascular risk factors. Better functional status. Thus smoking cessation counseling a CMS, JCAHO performance measure. 1. Reeves GR, et al. Arch Intern Med 2008;168:2111-7. 2. Critchley, et al. Cochrane Database Syst Rev. 2003:CD003041.doi:10.1002/14651858CD003041. 2. Wilson K, et al. Arch Intern Med 2000;160:939-44. ACC/AHA 2007 STEMI Guidelines Secondary Prevention Ask, advise, assess, and assist patients to stop smoking – I (B) Clopidogrel 75 mg daily: PCI – I (B) no PCI – IIa (C) Statin goal: LDL-C < 100 mg/dL – I (A) consider LDL-C < 70 mg/dL – IIa (A) Daily physical activity 30 min 7 d/wk, minimum 5 d/wk – I (B) Annual influenza immunization – I (B) Predictors of Smoking Cessation after MI PREMIER Registry- 19 centers, 639 smokers Discharge prescription for cardiac rehab: OR=1.80 (1.17-2.75). Treated at a facility that offered an inpatient smoking cessation program with at least one month of support after discharge: OR=1.71 (1.03-2.83). Depressive symptoms: OR=0.57 (0.36-0.90). Dawood N, et al. Arch Intern Med 2008:168:1961-7. Deaths Attributed to Smoking Heart Disease Stroke COPD Other Other Cancers Secondhand Smoke Lung Cancer Morbid Mortal Wkly Rep 2003;52:842-4. Respiratory Tract Effects Causes peribronchiolar inflammation and fibrosis, bronchospasm, increases mucosal permeability, impairs mucociliary clearance, changes pathogen adherence, disrupts respiratory epithelium, impairs immune response, carcinogenic. Acute and chronic sinusitis Acute and Chronic Obstructive Pulmonary Dis (X 13.1) Asthma, emphysema (24%) chronic bronchitis (49%), pneumonia, interstitial lung disease, bronchiolitis, pulmonary hypertension, respiratory failure, tuberculosis (X 4.5) Arcavi L. Arch Intern Med 2004;164:2206-16. Relative Risk - Respiratory Chronic Airway 10.58 Obstruction 6.8 Bronchitis, 17.1 Current Emphysema 15.64 Former Pneumonia, 1.75 Influenza 1.36 0 5 10 15 20 Relative Risk http://apps.nccd.cdc.gov/sammec/edit_risk_data.asp Lung Cancer About 28% of smoking-attributable deaths. In 2000 in US, 87% of the 184,000 new cases of lung cancer1 850,000 lung cancer deaths worldwide2. 3000 US lung cancer deaths attributed to secondhand smoke3. 10-year risk for a 68yo man with a 100-pack-yr history is 15%. Continued smoking shortens survival time5. 1. Ctrs Dis Contr. Morbid Mortal Wkly Rep 2003;52;842-4. 2. Ezrati M. Lancet 2003;362:847-52. 3. Amer Heart Assn 2005. 5. Bach PB, et al. J Natl Cancer Inst 2003;95:470-8. Lung Cancer – Dose Effect 41+ 80 31-40 66 21-30 48 Number of cigarettes/day 11-20 30 1-10 15 Non-Smoker 1 0 20 40 60 80 100 Relative Risk of Lung Cancer Wynder EL, Stellman SD. J Natl Cancer Inst 1979;62:471-7. Cancer Effects Carcinogenic – 60 chemical carcinogens Responsible for a third of all cancer deaths in western countries. Incidence of lung cancer deaths in the US has been steeply declining over the past ten years, first in men, and now in women as well. Sacco AJ, et al. Lung Cancer 2004;Suppl 2:S3-9. Relative Risk - Cancer Lip, Oral Cavity, Pharynx 11 3.4 Esophagus 6.8 4.5 Stomach 2 1.5 Pancreas 2.3 1.2 Current Larynx 15 6.3 Former Trachea, Lung, Bronchus 23 8.7 Uterine Cervix 1.6 1.1 Kidney & Renal Pelvis 2.72 1.7 Urinary Bladder 3.27 2.1 Acute Myeloid Leukemia 1.86 1.3 0 5 10 15 20 25 http://apps.nccd.cdc.gov/sammec/edit_risk_data.asp Gastrointestinal Effects Chronic destructive periodontal disease – the main risk factor. Relative risk X 5-20 vs never smoker1. Increased risk and severity, slower healing and greater recurrence of gastritis, gastroesophageal reflux, peptic ulcer disease (X 3.4-4.1)2. Increased Crohn’s Disease (X 2.0) and ischemic bowel. 1. Bergstrom J. Odontology 2004;92(1):1-8. 2. Mallamapalli A, et al. Med Clin N Amer 2004;1431-51. Smoking and Infection Cause structural changes in the respiratory tract and a decrease in immune response. 30% increased WBC, increased CD8+ counts, reduced IgG, IgA, IgM. reduced CD4+ counts in bronchoalveolar fluid. Inhibition of PMN chemotaxis and migration, NK cell activity. Decreases release of IL-1, IL-2, IL-6, TNF-α, IFN-γ. 2- to 5-fold increased risk of invasive pneumococcus. 1.5- to 2.2-fold risk of common cold. 1.4- to 2.4- fold influenza risk and more severe. Varicella, HPV, HIV prevalence and severity increased Increased risk of tuberculosis, especially important in underdeveloped countries. Increased risk of meningococcal disease, bronchitis, and otitis media in children exposed to secondhand smoke. Arcavi L. Arch Intern Med 2004;164:2206-16. Women and Smoking Smoking reduces the average life expectancy1 by: 14.5 years for females. 13.2 years for males. Facilitates the metabolism of estrogen, increasing risk of cardiovascular disease, osteoporosis (80% higher fracture risk), cervical cancer, and wrinkles. Increased susceptibility of women to develop lung cancer in response to smoking which is more virulent and at an earlier age than in men2. In 2000, exceeded breast, uterine, and ovarian cancer death combined in women. ¼ of all cancer deaths in women. Doubles the risk of DVT and PTE among OCP users3. 1. US Surgeon General May 2004. 2. Reuters January 31, 2005. 3. Reichert VC, et al. Med Clin N Amer 2004;88:1467-81. Women and Smoking The Nurses’ Health Study 104,519 nurses age 30-55 followed 1980-2004. At baseline (1980), 45.7% never smoked 26.0% past smokers 28.3% current smokers In 2002, only 8% of those alive were current smokers. Among current smokers, 64% of all deaths were directly attributable to smoking. Among former smokers, 28% of deaths attributable to smoking. Kenfield SA, et al. JAMA 2008;299:2037-47. Mortality Among Women Nurses’ Health Study 4.43 4.5 4 3.67 3.5 2.92 3 2.77 Hazard Ratio 2.5 1.98 of Death 2 1.5 1.23 1 1 0.5 0 Never Past Current 1-14 15-24 25-34 >34 Smoking Status Cigarettes per Day Kenfield SA, et al. JAMA 2008;299:2037-47. Causes of Death in Women Cardiovascular & “Unrelated Cancer” 1.8 Current Other Causes 1.1 1 Past 1.6 Never Other Cancers 1 1 Colorectal 1.7 1.1 Cancer 1 Cerebrovascular 2.8 1.1 Disease 1 Coronary Heart 3.3 1.1 Disease 1 Vascular 3 Disease 1.1 1 0 1 2 3 4 Kenfield SA, et al. JAMA 2008;299:2037-47. Causes of Death in Women Respiratory & “Related Cancer” 1.6 Other Cancers 1 1 Current 1.7 Past Colorectal Cancer 1.1 Never 1 7.3 Smoking-Related Cancers 2.1 Lung, AML, bladder, kidney, cervix, esophagus, lip, 1 mouth, pharynx, pancreas, stomach, larynx 22 Lung Cancer 4.9 1 56 COPD 14 1 12 Respiratory Disease 3.3 1 0 10 20 30 40 50 60 Kenfield SA, et al. JAMA 2008;299:2037-47. Smoking and Pregnancy Increased infertility (X 1.36), spontaneous abortions, ectopic pregnancies (X 1.9). Increases prematurity and fetal death. Low birth weight doubles. Increased risk of placenta previa, pre-eclampsia. Sudden Infant Death Syndrome – 10% of all infant deaths. Negative toddler behavior –cranky, restless, sick more often, learning problems. Morbid Mortal Wkly Rep 2002;51:i-iv,1-13. Pregnancy & Long-Term Vascular Damage to Children Atherosclerosis in Young Adults study-births from 1970-1973, follow-up at 28.4 years. At birth offspring lighter and shorter at birth Heavier (p=.001) and higher SBP (p=.02) as adolescents. Heavier (p=.004), shorter (p=.02), more likely to smoke (p=.006) as adults. At age 28, Carotid IMT 13.4 μm greater if mother smoked (p=0.001) 12.4 μm greater if father smoked (p=.002) Greater if both smoked (p=.001) Geerts C, et al. Arterioscler Thromb Vasc Biol 2008: DOI: 1161/ATVBAHA.108.173229. Drug Metabolism Enhanced clearance of: theophyllline, tacrine, propranolol, diazepam, chlordiazepoxide, estrogen Reduces the metabolism of drugs by the cytochrome P450 pathway: warfarin Reduces levels of fluvoxine, imipramine. Increases levels of clozapine. Metz CN, et al. Med Clin N Amer 2004;1399-1413. Other Medical Problems Increases the risk of: Dementia & Alzheimer’s (X 2) and cognitive dysfunction (X 1.5). Insulin resistance and risk (X 1.45-1.94) and severity of diabetes. Grave’s Disease and ophthalmopathy. Cataracts. Severity of rheumatoid arthritis. Impotence (X 2.5). Psoriasis. Sundaram R, et al. Med Clin N Amer 2004;1391-7. Mallamapalli A, et al. Med Clin N Amer 2004;1431-51. Sabia S, et al. Arch Intern Med 2008:168:1165-73. Smokeless Tobacco Snuff, chewing, or “spit” tobacco. Used by 5 million adults and more than 750,000 adolescents. Increases risk of oral cancer, dental problems such as receding gums, bone loss, and bad breath. Increased heart rate by 16 bpm, blood pressure by 10 mm Hg, and epinephrine by 50% among 16 healthy young men. Wolk R. J Amer Coll Cardiol 2005;45:910-4. Secondhand Smoke Secondhand smoke exposure is responsible for 38,000 deaths including 3000 lung cancer deaths annually in the US1. Living with a smoker increases the risk of ischemic heart disease death by 30-57%3-5. 1. www.americanheart.org. 3. Bartecchi, C, et al. Circulation 2006;114:1490-6. 4. Taylor AE, et al. Circulation 1992;86:699-702. 5. Barnoya J, et al. Circulation 2005;111:2684-98. Secondhand Smoke May rapidly precipitate atherothrombotic events. Increases CRP, fibrinogen, and ox-LDL similar in magnitude to smokers. Increases platelet aggregation, augments MMP activity, thus plaque destabilization Decreases HDL, causes mitochondrial damage, insulin resistance. 30 minutes SHS impairs coronary endothelial function and increases aortic stiffness similar to smokers. Reduces heart rate variability. Barnoya J, et al. Circulation 2005;111;2684-98 Clean Indoor Air & Acute Coronary Syndromes In Helena, MT, there was a 40% reduction in the number of heart attacks with a clean indoor air policy, that returned to prior levels when it was overturned.2 In Pueblo, CO, there was a 27% reduction in heart attacks over the 18-month period after a comprehensive public Smoke-Free Air Act = a reduction by 70/100,000/year vs. no change in Colorado Springs during the same period. 3 In Scotland, in the year after smoke-free legislation in March 2006 there was a 17% reduction in hospital admissions for acute coronary syndromes (95% CI 16-18%) vs a 4% reduction in England. This was a reduction of 14% among smokers, 19% among former smokers, and 21% among never smokers. 1. Ritter J. USA Today March 9, 2005:7D. 2. Bartecchi, C, et al. Circulation 2006;114:1490-6. 3. Pell JP, et al. N Engl J Med 2008;359:482-91. Secondhand Smoke Pre-school age children exposed to their parents’ smoke are 20% more likely to get middle ear infections. Maternal smoking ½ ppd increases COPD risk 70% in their children2. March 8, 2005 California Air Resources Board links passive smoking to a 26-90% increased risk of breast cancer3. 2. Reichert VC, et al. Med Clin N Amer 2004;88:1467-81. 3. Ritter J. USA Today March 9, 2005:7D. States with Restrictions as of 12/31/07 Restrictions in private-sector worksites in 37 (39) states. Restrictions in restaurants in 41, but not in: AL. Smoke-free in 21 states. Restrictions in bars in only 20. Smoke-free in 13 states. As of 2003, 77% of US workers in a smoke-free workplace. MMWR 2008 57(20):549-52. American Cancer Society Alabama Survey Of 500 registered Alabama voters who participated: 78% responded in favor of a law making all Alabama workplaces smoke-free. 95% viewed secondhand smoke as at least some kind of health hazard. 92% agreed no one should be exposed to secondhand smoke in the workplace. 79% responded that it is the government's responsibility to promote and protect public health. 81% said they were likely to vote in the next election. Performed by Little rock-based Opinion Research Associates January 2008 Coalition for a Tobacco-Free Alabama Alabama Academy of Family Physicians Alabama Citizens Action Program (ALCAP) Alabama Department of Public Health Alabama Faith United Against Tobacco Alabama Sports Festival Alabama State Nurses Association American Academy of Pediatrics - Alabama Chapter American Cancer Society American College of Cardiology - Alabama Chapter American Heart Association Alabama Lung Association Blue Cross Blue Shield DuBois Institute Medical Association for the State of Alabama Other Impacts Personal Expense Cigarettes- At $3.27/pack, 1ppd X 50 years will cost $59,677 in 2005 dollars. Duke economist Frank Sloan estimates at $40/pack or $220,000 for a 24YO man in The Price of Smoking. Cost of cigarettes + excise taxes. Life and property insurance. Medical care for the smoker and his family. Lost earnings due to acute illness and disability. Lost receipt from private pensions, social security and Medicare due to early death. Reduced quality of life due to illness and disability. Lost retirement (life expectancy about 67 years). WalMart April 5, 2005. Duke Magazine 2005;91:17. Sloan FA, et al. The Price of Smoking 2004. The MIT Press, Cambridge, MA. Other Impacts Societal Expense $76 billion societal medical expense: $27 billion ambulatory $19 billion nursing home $17 billion hospital $6.4 billion prescription drugs $5.4 billion other $98 billion in lost productivity costs annually. $204 billion total cost. http://apps.nccd.cdc.gov/sammec/computations.asp Smoking and Health-Related Quality of Life in Old Age 1658 healthy white men in Helsinki Businessman Study 40-55 YO enrolled 1974, surveyed 2000 Never smokers lived ten years longer, and their extra years were of better quality. Health-related quality of Life (HRQoL) measured with Rand 36-Item Health Survey Strandberg AY, et al. Arch Intern Med 2008: 168:1968-74 The unadjusted association of smoking status and the number of cigarettes smoked daily at baseline in 1974 and mortality during the 26-year follow-up period . Strandberg, A. Y. et al. Arch Intern Med 2008;168:1968-1974. The age-adjusted association of smoking status at baseline in 1974 and health-related quality of life as RAND 36-Item Health Survey (RAND-36) scores in 2000 Strandberg, A. Y. et al. Arch Intern Med 2008;168:1968-1974. Other Impacts - Social Hygiene and odor distasteful to others Wrinkles (X 2.3-4.7) and smokers’ nails Loss of credibility with one’s children: “You’re doing something you know is bad for you!” Learned lack of self-control increases children’s chances of addiction to cigarettes and other substances as well as other behavior patterns. Prevalence of Smoking > 18yo National Health Interview Survey 23.9% 20.8% 18.0% 45.3 million current smokers in the US 45.7 million former smokers MMWR 2007;56(44)1157-61. Smoking in Alabama The percentage of Alabamians who smoked has gone down from 30.6% in 1990 to 25.3% in 2002 to 23.2% in 2006. We receive $100,000,000 a year from the $206 billion Master Settlement Agreement. Only a few hundred thousand dollars go to tobacco prevention and cessation programs. In 2005, national tobacco-industry marketing expenditures were 13.1 billion dollars. Birmingham News November 23, 2004. MMWR 2007;56(44):1157-61. Smoking and Children 80% of adult smokers began before age 18. Every day Nearly 4000 children under age 18 try their first cigarette. 2000 children under age 18 become regular smokers. American Heart Association 2005. CDC April 1, 2005. MMWR 2008;57(25):689-91. Smoking Frequency Among High School Students -restricted advertising 80 -counter-advertising 70 -less in movies and videos 60 -smoke-free ordinances 50 -reduced availability Ever 40 Current 30 days 30 Current frequent 20 -school-based tobacco- use prevention policies 10 and procedures -higher price + excise tax 0 1991 1995 1999 2003 2007 -reduced parental and societal prevalence MMWR 2008;57(25):689-91. Cigarette Use - Age 12-17yo 50 18-25yo 45 >25yo 40 25-44 35 45-64 30 >65 25 20 15 10 5 0 1985 1999 2000 2001 2006 The World Almanac 2003. MMWR 2007;56(44):1157-61. Global Cigarette Consumption 6000 5000 Annual Global 4000 Cigarette 3000 Consumption (in billions) 2000 1000 0 1960 1970 1980 1990 2000 This is 50 packs of cigarettes for every man, woman, and child on the planet!! World Health Organization. http://www.who.int.tobacco/en/atlas8.pdf Worldwide Tobacco Use 1 billion male smokers and ¼ billion female smokers1. The average Chinese man smokes 16 cigarettes/day 2. In developed countries, 35% of men and 22% of women smoke; whereas in developing countries, 58% of men and only 9% of women smoke1. 4.83 million deaths attributed to smoking in 20003. 1. Mackay J and Eriksen MP. The Tobacco Atlas. Geneva:WHO;2002. 2. Knight E, et al. CRS Report for Congress; 1998. 3. Ezrati M and Lopez AD. Lancet 2003;362:847-52. Benefits of Quitting People who quit smoking before age 50 have half the risk of dying over the next 15 years of those who continue to smoke1. Within a year of quitting the excess risk of a heart attack is reduced 80%.2. Within 2 wks of quitting platelet aggregation is reduced3. Smoking cessation improves pulmonary function 20-30% within 2 to 3 months4. Ten years after quitting the risk of lung cancer is reduced 50%4. 1. Ctrs for Dis Contr Prev. Morbid Mortal Wkly Rep 1990;39:2-10. 2. Wilhelmsson C, et al. Lancet 1975;1:415-20. 3. Morita H. Circulation 2005;45:589-94. 4. Jorenby DE. Circulation 2001;104:e51-2. Smoking Cessation “Stopping smoking is easy. I’ve done it a thousand times.” Mark Twain Smoking Cessation In 20001 68% of smokers wanted to quit (US and Europe) 40% tried to quit 5% succeeded in quitting Personal Motivation is the most important factor as to whether someone will quit smoking. Hospitalization, especially with a heart attack, is the most susceptible period that people have to be successful recipients of smoking cessation counseling. After a heart attack 71% of people in an aggressive smoking cessation program will quit smoking2. In the Medicare database, those who received smoking cessation counseling prior to discharge post-MI were 20% more likely to survive 30 days, as well as 60 days, and one year3. 1. American Heart Association. 2. Taylor CB, et al. Ann Intern Med 1990;113; 118-23. 3. Houston TK. Am J Med 2005;118:269-75. Medicare and Smoking 9.3% of those over 65 smoke. 10% quit each year. Elderly account for 300,000 of the 440,000 deaths each year from smoking. Smoking costs HHS 14.2 billion dollars/year, 10% of its total budget. 1-800-QUIT-NOW and www.smokefree.gov Alabama Tobacco Quitline 1-800-QUITNOW Set up by CDC for any interested Alabamians. Telephone counseling service. Referral to local smoking cessation services. Educational materials. Consultation for implementation and training on the USPHS Clinical Practice Guidelines for Treating Tobacco Use and Dependence. Provide nicotine replacement therapy coupons. Alabama MD 2005;41:1-3. Quitting Smoking A recommendation by a health care provider will increase chances of success by 30%. Behavioral treatment increases chances of success by 50%. Identification of and avoidance or coping with smoking triggers. Social support by a clinician, family, friends, co- workers. Zbikowski SM, et al. Med Clin N Amer 2004;88:1453-65. Public Health Service Guidelines – The 5A Model 1. Ask about smoking- every patient every visit. 2. Advise one to quit- in a clear, strong personalized manner. 3. Assess willingness to quit. 4. Assist those willing to quit. 1. If willing, offer medication, and provide or refer for counseling or additional treatment. (1-800-QUITNOW.) 2. If unwilling, provide interventions designed to increase future quit attempts. 5. Arrange for follow-up- if willing, at a week and a month. If unwilling, address again at next visit. Fiore MC, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville (MD): US Dept Health Human Svcs Public Health Svc; 2008 Update. Assist those willing to quit. Set a quit date, ideally within two weeks. Tell family, friends, and co-workers about quitting, and request understanding and support. Anticipate challenges such as nicotine withdrawal, particularly during the first few critical weeks. Remove tobacco products from your environment. Prior to quitting, avoid smoking in places where you spend a lot of time such as home, work, car. Make your home smoke-free. Recommend the use of medications to reduce withdrawal symptoms. Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS. PHS. May 2008. Assist those willing to quit. Total abstinence. Past quit experience. Anticipate triggers/ alter routines: alcohol, morning cup of coffee, weekly poker game. Other smokers in the household. Provide a supportive clinical environment. Provide other sources of help. 1-800-QUIT-NOW, www.smokefree.gov, Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS. PHS. May 2008. Quitting and Medications Nicotine supplements – gum, patches, lozenges, inhalers, nasal spray Anti-depressants Buproprion SR (Wellbutrin SR or Zyban) Nortryptilline and clonidine (not approved for this use, listed as second-line in the guidelines) Varenicline (Chantix) -nicotine-receptor partial agonist Rimonabant (not available) –cannabanoid receptor blocker NicVax* and Ta-Nic* trigger the production of antibodies that bind to nicotine molecules and prevent them from reacting with receptors in the brain. Should all be used in combination with counseling *Currently in clinical trials Transdermal Nicotine + Nortryptiline vs Placebo 70 60 50 Nicotine + 40 % Quit Nortryptiline 75 mg 30 Nicotine + Placebo Nicotine 20 Nortryptiline 18/79 (23%) vs 8/79 10 (10%); p=0.052 0 Clonidine also listed as QD 30 60 90 120 150 180 second-line treatment Days since Quit Date in the guidelines. Prochazka A, et al. Arch Intern Med 2004;164:2229-33. Buproprion SR 12-Month Abstinence Rate p<.001 40.00% p<.001 35.00% 30.00% 25.00% 20.00% 15.00% Nicotine Buproprion Buproprion+ Placebo NRT 10.00% Replacement N=160 N=244 N=245 N=244 5.00% 0.00% 150 mg po qd X 3 days, then 150 mg po bid. Jorenby DE, et al: NEnglJMed 1999;340:685-91. Varenicline - Chantix After inhalation, nicotine predominantly binds to the nicotinic aceylcholine (nACh) receptors located in the mesolimbic- dopamine system of the brain within a matter of seconds. Nicotine specifically activates 4β2 nicotinic receptors in the Ventral Tegmental Area (VTA) causing an immediate dopamine release at the Nucleus Accumbens1 (nAcc). The dopamine release is believed to be a key component of the reward circuitry associated with cigarette smoking1. Varenicline is a selective α4β2 nicotinic receptor partial agonist. Reduces the rewarding and reinforcing effects of nicotine. Picciotto MR, et al. Nicotine Tob Res. 1999; Suppl 2:S121-125. Varenicline vs Placebo Varenicline Placebo Adverse Effect % of subjects Nausea 35.8 11.2 Insomnia 22.0 12.7 Abnormal dreams 14.4 5.0 Headache 16.8 14.3 Other GI effects* 22.5 11.8 Stop due to AE 12.0 8.1 *vomiting, constipation, diarrhea, flatulence, dyspepsia. Hays JT, and Ebbert JO. N Engl J Med 2008:359:2018-24 . Varenicline Essentially no metabolism, 80% excreted unchanged in urine. No meaningful drug-drug interactions. Start at 0.5 mg/day for 3 days, 0.5 bid for 4 days, then 1.0 mg bid for 3-6 months. Can reduce dosage to 1.0 mg daily for nausea. Can reduce to 0.5 mg daily for Cr Clearance < 30 cc per min or dialysis patients. Removed with dialysis. Use with GETQUIT Support Program, 1-800-QUIT- NOW, www.smokefree.gov. Hays JT, and Ebbert JO. N Engl J Med 2008:359:2018-24. Assist those unwilling to quit. Motivational Interviewing 1. Express empathy. 2. Develop discrepancy. 3. Roll with resistance. 4. Support self-efficacy. Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS. PHS. May 2008. Assist those unwilling to quit. Enhancing motivation to quit- The 5 R’s 1. Relevance-personalize to disease states, family situation. 2. Risks- 1. Acute- SOB, asthma flares, sinusitis, ulcers, pregnancy. 2. Long-term- MI, CVA, COPD, cancer. 3. Environmental- spouse, infants, children. 3. Rewards- health, taste, smell, money, self-image, impact on children’s habits, health of family, SOB, nails, teeth, wrinkles, quality of life, life expectancy, retirement. 4. Roadblocks- withdrawal, “reduced stress” myth, fear of failure, weight gain, lack of support- do for yourself. 5. Repetition every visit- most people make repeated quit attempts. Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Arrange follow-up. Contact within the first week, and again within the first month, then as needed. Identify problems encountered, and anticipate challenges in the future. Assess medication use and problems. Remind of Quitline/support. Congratulate them on their successes, and encourage complete abstinence. Continue to assess use at every visit, and provide feedback. Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS. PHS. May 2008. Summary Smoking is far and away the most important behavior affecting life expectancy and long-term health of smokers. 64% die as a result. Educate and Motivate your patient: “If you smoke, carefully consider what reasons you use to commit yourself to continuing to smoke, and what factors about your health and future relationships might motivate you to quit.” “You can quit! I would love to assist you!” Use the 5 A’s, medications, and other resources. Conclusion “Sparing a few minutes for tobacco cessation: if only half of all nurses helped one patient per month quit smoking, more than 12 million smokers would overcome their addictions every year.” Bialous SA, Sarna L. Am J Nurs. 2004;104(12):54-60. Atherosclerosis A process that builds up plaque inside the walls of arteries or blood vessels that carry blood to the organs of the body. May reduce the blood flow to these organs gradually. May form blood clots which rapidly reduce blood flow. May cause spasm in these arteries. Atherosclerosis Major Organs Affected Heart - coronary artery disease Angina or chest discomfort, shortness of breath Myocardial infarction Congestive heart failure Arrhythmias and sudden death Brain – cerebrovascular disease Stroke and transient ischemic attack Peripheral vascular disease Claudication, skin ulcers, wound healing, gangrene, aneurysms Atherosclerosis Risk Factors Factors that increase the risk and severity of atherosclerosis: Modifiable and un-modifiable Cigarette Use By Gender 60 50 40 Male 30 Female 20 10 0 1965 1970 1975 1980 1985 1990 1995 2000 2003 45.4 million smokers in the US. http://www.cdc.gov/nchs. Cigarette Use - Education 45 40 35 30 Non-high school grads 25 High school grads 20 Some college 15 College grads 10 5 0 1985 1999 2000 2001 2006 MMWR 2007;56(44):1157-61. Nicotine Pleasurable effects: Arousal Relief of anxiety Nicotine withdrawal: Irritability, frustration, anger Dysphoric or depressed mood Anxiety Difficulty concentrating Restlessness Increased appetite or weight gain Decreased heart rate Insomnia DSM-IV. Washington, DC.:American Psychiatric Association. 1994. Nicotine pharmacokinetics Rapid absorption from smoke due to large pulmonary capillary surface area Rapid transit directly to the brain undiluted Immediate rapid rise in nicotine levels Binding and conformational change in pentameric nicotinic acetylcholine receptors in Nucleus accumbens Mesolimbic system-reward center of the brain- highest concentrations of high affinity 42 Ventral tegmental area Henningfield JE, et al. Drug Alcohol Depend 1993:33:23-9. Watkins SS, et al. Nicotine Tob Res 2000:2:19-37. The Actions of Nicotine and Varenicline in the Brain Hays J and Ebbert J. N Engl J Med 2008;359:2018-2024 Varenicline - Chantix A selective α4β2 nicotinic receptor partial agonist developed by Pfizer. Reduces the rewarding and reinforcing effects of nicotine. A randomized placebo-controlled trial of Varenicline 0.5 mg bid (N=253) vs Varenicline 1.0 mg bid (N=253) vs Placebo (N=121) Oncken C. American College of Cardiology Meeting, March 8, 2005. Varenicline - Quit Rate 60 50.6 50 45.1 40.7 40 37.2 Placebo Quit Rate (%) 30 Varenicline 0.5 mg bid (N=253) Varenicline 1.0 mg bid 20 (N=253) 11.6 12.4 10 All values p <0.0001 vs placebo 0 Weeks 4-7 Weeks 9-12 Oncken C. American College of Cardiology Meeting, March 8, 2005. Treating Tobacco Use and Dependence: 2008 Update Tobacco use presents a rare confluence of circumstances: A highly significant health threat; A disinclination among clinicians to intervene consistently; The presence of effective interventions. Indeed it is difficult to identify any other condition that presents such a mix of lethality, prevalence, and neglect, despite effective and readily available interventions. Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS. PHS. May 2008. Why should a busy clinician consider making treatment of tobacco use a priority? 1. Clinicians make a difference with even a minimal (<3 minute) intervention. 2. A relation exists between the intensity of intervention and tobacco cessation outcome. 3. Even when patients are not willing to make a quit attempt at this time, clinician-delivered brief interventions enhance motivation and increase the likelihood of future quit attempts. 4. Tobacco users are being primed to consider quitting by a wide range of societal and environmental factors (e.g., public health messages, family members). Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS. PHS. May 2008. Why should a busy clinician consider making treatment of tobacco use a priority? 5. There is growing evidence that smokers who receive clinician advice and assistance with quitting report greater satisfaction with their health care than those who do not. 6. Tobacco use interventions are highly cost-effective. 7. Tobacco use has a high case fatality rate (>50% of long-term smokers will die of smoking related disease. Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS. PHS. May 2008. Abstinence Rates by # Treatment Sessions Meta-analysis 46 studies Number of Number Estimated Odds Ratio Estimated Abstinence Sessions of arms (95% CI) Rate (95% CI) 0-1 session 43 1.0 12.4 2-3 sessions 17 1.4 (1.1-1.7) 16.3 (13.7-19.0) 4-8 sessions 23 1.9 (1.6-22) 20.9 (18.1-23.6) >8 sessions 51 2.3 (2.1-3.0) 24.7 (21.0-28.4) Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS. PHS. May 2008. Secondary Prevention and Long Term Management Goals Class I Recommendations Smoking •Status of tobacco use should be asked at every 2007 Goal: visit. Complete •Every tobacco user and family member who cessation. smoke should be advised to quit at every visit. No exposure to •The tobacco user’s willingness to quit should be environmental assessed. NEW tobacco smoke. •The tobacco user should be assisted by counseling and developing a plan for quitting. •Follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and pharmacological rx) should be arranged. •Exposure to environmental tobacco smoke at home and work should be avoided. NEW Prolonged Abstinence Placebo Rimonabant 5mg OR=2.2 - 95%CI=[1.374;3.456] Rimonabant 20mg p=0.002 Percent 40 OR=2.0 - 95%CI=[1.296;3.046] 36.2 Abstinent p=0.004 35 (%) 30 27.6 25 20.6 20.2 20 16.1 15.6 15 10 5 0 N=261 N=262 N=261 N=189 N=183 N=188 ITT Completers STRATUS-US Study. American College of Cardiology Meeting, March 2004. Camel late 1940s Brandt, AM. N Engl J Med 2008;359;445-8. “Reports of serious drug reactions hit record” The FDA should forcefully warn patients taking Chantix that they may have blackouts and other problems that could lead to accidents, the report said. The current warnings say that patients may be too impaired to drive or operate heavy machinery, but such language is standard for many medications. The report found 15 cases of Chantix patients who appeared to have been involved in traffic accidents, and 52 additional cases involving blackouts or loss of consciousness. The FDA received 1,001 reports of serious injuries possibly linked to Chantix, more than for the ten best-selling brand name drugs combined. Chantix "continued to provide a striking signal of safety issues that require investigation and action," the report said. The authors acknowledged Pfizer's concern that publicity may be driving up the number of reports, but nonetheless concluded that there are enough to warrant further action by the FDA. Pfizer said the total sum of its data on Chantix, including results from clinical trials, show that the drug's benefits clearly outweigh its risks. "We stand by the efficacy and safety profile of Chantix," the company said in a statement. "There are few things that provide greater health benefits than quitting smoking. Pfizer is committed to reducing the prevalence of smoking globally. As part of that mission, we want to increase peoples' understanding of the dangers of smoking and the benefits of quitting." Alonso-Zaldivar R. The Boston Globe. 10/22/08 Restrictions on use of Varenicline Monitor patients closely if adverse behavioral effects are noted by patient or family. Report if suspected. Package insert: safety concerns wile operating heavy machinery. FAA: pilots and air-traffic controllers may not use varenicline. ..also by the organization overseeing interstate commercial truck and bus drivers. Hays JT, and Ebbert JO. N Engl J Med 2008:359:2018-24 States with Restrictions as of 12/31/07 Restrictions in private-sector worksites in 37, but not in: AK, IN, KS, KY, (MD), (MI), MS, NC, SC, TX, VA, WV, WY. Restrictions in restaurants in 41, but not in: AL, IN, KY, MS, NC, SC, TX, WV, WY. Smoke-free in 21 states. Restrictions in bars in only 20. Smoke-free in 13 states. As of 2003, 77% of US workers in a smoke-free workplace. MMWR 2008 57(20):549-52.