Smoking by uY1cCm1


The Talk You’ve Never Heard

        Michael B. Honan, MD
     CardioVascular Associates, PC
      Brookwood Medical Center
          December 30, 2008
   None
   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
     •   “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
Deaths Attributed to Smoking
                            Heart Disease



       Other Cancers

                       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
Ischemic Heart Disease                                   2.8
   Other Heart Disease                     1.78
Cerebrovascular Disease                                        3.27
                                      1.04                                                 Current
        Atherosclerosis                             2.44                                   Former
       Aortic Aneurysm                                                          6.21
  Other Arterial Disease                          2.07

                           0      1           2          3          4   5   6          7
                               Relative Risk of Cardiovascular Events
     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
       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



       Other Cancers

                       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,
 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
               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
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
                      Esophagus                       6.8
                        Stomach          2
                        Pancreas          2.3
                          Larynx                                     15
                                                   6.3                              Former
        Trachea, Lung, Bronchus                                                23
                   Uterine Cervix        1.6
           Kidney & Renal Pelvis          2.72
                 Urinary Bladder           3.27
        Acute Myeloid Leukemia           1.86

                                    0          5         10         15    20   25
    Gastrointestinal Effects
   Chronic destructive periodontal disease – the
    main risk factor. Relative risk X 5-20 vs never
   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

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                                                   3.67
               3                    2.77
Hazard Ratio 2.5
  of Death     2
             1.5            1.23
                   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
      Colorectal                      1.7
       Cancer                  1
Cerebrovascular                              2.8
    Disease                    1
Coronary Heart                                     3.3
   Disease                     1
        Vascular                              3
        Disease                 1.1

                      0        1         2   3           4
Kenfield SA, et al. JAMA 2008;299:2037-47.
   Causes of Death in Women
 Respiratory & “Related Cancer”
                            Other Cancers                      1
                                                               1                                          Current
                                                               1.7                                        Past
                     Colorectal Cancer                         1.1

    Smoking-Related Cancers                                     2.1
     Lung, AML, bladder, kidney, cervix, esophagus, lip,       1
     mouth, pharynx, pancreas, stomach, larynx
                               Lung Cancer                         4.9

                                            COPD                             14

                 Respiratory Disease                               3.3

                                                           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
   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
       Insulin resistance and risk (X 1.45-1.94) and severity of
       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
   Increases risk of oral cancer, dental problems
    such as receding gums, bone loss, and bad
   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. 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
        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
   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
   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
   Restrictions in private-sector worksites in 37 (39)
   Restrictions in restaurants in 41, but not in: AL.
    Smoke-free in 21 states.
   Restrictions in bars in only 20. Smoke-free in 13
   As of 2003, 77% of US workers in a smoke-free
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 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.
 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


          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
     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
70                                        -less in movies and videos
60                                        -smoke-free ordinances

50                                        -reduced availability
                                             Current 30 days
30                                           Current frequent
20                                        -school-based tobacco-
                                          use prevention policies
10                                        and procedures
                                          -higher price + excise tax
      1991   1995    1999   2003   2007   -reduced parental and
                                          societal prevalence
MMWR 2008;57(25):689-91.
        Cigarette Use - Age
30                                                              >65
       1985        1999       2000        2001           2006

     The World Almanac 2003. MMWR 2007;56(44):1157-61.
Global Cigarette Consumption


 Annual Global 4000
  (in billions) 2000


                       1960      1970       1980       1990       2000
         This is 50 packs of cigarettes for every man, woman,
         and child on the planet!!
 World Health Organization.
    Worldwide Tobacco Use
   1 billion male smokers and ¼ billion female
   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
        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
   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

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
    Alabama Tobacco Quitline
   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-

    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
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
   Recommend the use of medications to reduce withdrawal

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,,
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
   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
                                                                 Nicotine +
% Quit

                                                                 Nortryptiline 75 mg
         30                                                      Nicotine + Placebo
               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
15.00%                     Nicotine Buproprion Buproprion+
                  Placebo                         NRT
10.00%                    Replacement
                  N=160               N=244      N=245
    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       .
   Essentially no metabolism, 80% excreted unchanged in
   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-

    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
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
Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice
   Guideline. Rockville, MD: USDHHS. PHS. May 2008.
   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.

   “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.
   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
     May cause spasm in these arteries.
    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,
           Risk Factors

   Factors that increase the risk and severity of
   Modifiable and un-modifiable
 Cigarette Use By Gender




     1965   1970   1975   1980   1985   1990   1995   2000   2003
            45.4 million smokers in the US.
Cigarette Use - Education
30                                             Non-high school grads
25                                             High school grads
20                                             Some college
15                                             College grads
        1985    1999    2000     2001   2006

     MMWR 2007;56(44):1157-61.
   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 42
         Ventral tegmental area
Henningfield JE, et al. Drug Alcohol Depend 1993:33:23-9. Watkins SS, et al. Nicotine Tob Res
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
   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
                50                               45.1
                40          37.2                               Placebo
Quit Rate (%)

                30                                             Varenicline 0.5 mg bid
                                                               Varenicline 1.0 mg bid
                20                                             (N=253)
                     11.6                 12.4
                10                                             All values p <0.0001
                                                               vs placebo
                       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
        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)
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
                 •Exposure to environmental tobacco smoke at
                  home and work should be avoided.        NEW
                      Prolonged Abstinence
    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
           30                            27.6

                                                         20.6     20.2
           20           16.1     15.6
                       N=261    N=262    N=261          N=189     N=183   N=188

                        ITT                            Completers
      STRATUS-US Study. American College of Cardiology Meeting, March 2004.
                                           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

      Alonso-Zaldivar R. The Boston Globe. 10/22/08
       Restrictions on use of
   Monitor patients closely if adverse behavioral
    effects are noted by patient or family. Report if
   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
   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
   Restrictions in bars in only 20. Smoke-free in 13 states.
   As of 2003, 77% of US workers in a smoke-free

MMWR 2008 57(20):549-52.

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