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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.
•
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.
1.
2.
3.
4.
5.
Ask about smoking.
Advise one to quit.
Assess willingness to quit.
Assist those willing to quit.
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.
•
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.
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.

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.
Heart Disease
Stroke
COPD
Other
Other Cancers
Secondhand
Smoke
Lung Cancer
Morbid Mortal Wkly Rep 2003;52:842-4.

Unmodifiable

Modifiable
› Age
› Cigarette smoking
› Family history of early
› Hypertension
CAD
› Male gender
› Genetic factors
› African-American
› Cholesterol-HDL, LDL,
› Triglycerides
› Diabetes
› Overweight
› Poor diet
› Lack of regular
exercise
› Cocaine/crack use
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.


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.

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.





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.
Ischemic Heart Disease
2.8
1.64
1.78
1.22
Other Heart Disease
Cerebrovascular Disease
3.27
1.04
Atherosclerosis
1.33
Current
Former
2.44
Aortic Aneurysm
6.21
3.07
Other Arterial Disease
2.07
1.01
0
1
2
3
4
5
6
Relative Risk of Cardiovascular Events
http://apps.nccd.cdc.gov/sammec/edit_risk_data.asp
7






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.
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)


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.
Heart Disease
Stroke
COPD
Other
Other Cancers
Secondhand
Smoke
Lung Cancer
Morbid Mortal Wkly Rep 2003;52:842-4.
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.
10.58
Chronic Airway
Obstruction
6.8
Bronchitis,
Emphysema
17.1
15.64
Current
Former
1.75
1.36
Pneumonia,
Influenza
0
5
10
15
Relative Risk
http://apps.nccd.cdc.gov/sammec/edit_risk_data.asp
20
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-packyr 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.
41+
80
31-40
Number of
cigarettes/day
66
21-30
48
11-20
30
1-10
15
Non-Smoker
1
0
20
40
60
80
Relative Risk of Lung Cancer
Wynder EL, Stellman SD. J Natl Cancer Inst 1979;62:471-7.
100

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.
Lip, Oral Cavity, Pharynx
11
3.4
Esophagus
4.5
Stomach
2
1.5
Pancreas
2.3
1.2
Larynx
6.8
6.3
Trachea, Lung, Bronchus
Current
Former
15
23
8.7
1.6
1.1
Uterine Cervix
Kidney & Renal Pelvis
2.72
1.7
Urinary Bladder
3.27
2.1
1.86
1.3
Acute Myeloid Leukemia
0
5
10
15
http://apps.nccd.cdc.gov/sammec/edit_risk_data.asp
20
25
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.

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.

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
more2 virulent and at an earlier age than in
men . 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
3
users .
1. US Surgeon General May 2004. 2. Reuters January 31, 2005. 3. Reichert
VC, et al. Med Clin N Amer 2004;88:1467-81.


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.
4.43
4.5
4
3.67
3.5
3
2.77
Hazard Ratio 2.5
2
of Death
1.5
1
2.92
1.98
1.23
1
0.5
0
Never
Past
Current
Smoking Status
Kenfield SA, et al. JAMA 2008;299:2037-47.
1-14
15-24
25-34
Cigarettes per Day
>34
Other Causes
Other Cancers
1.1
1
1
1
Colorectal
Cancer
1.1
1
Cerebrovascular
Disease
1.1
1
Coronary Heart
Disease
1.1
1
Vascular
Disease
1.1
1
1.8
Current
Past
Never
1.6
1.7
0
1
2
Kenfield SA, et al. JAMA 2008;299:2037-47.
2.8
3.3
3
3
4
Other Cancers
1.6
1
1
Colorectal Cancer
1.7
1.1
1
Smoking-Related Cancers
2.1
1
Lung, AML, bladder, kidney, cervix, esophagus, lip,
mouth, pharynx, pancreas, stomach, larynx
Lung Cancer
1
COPD
Current
Past
Never
7.3
1
0
Kenfield SA, et al. JAMA 2008;299:2037-47.
56
14
1
Respiratory Disease
22
4.9
3.3
10
12
20
30
40
50
60

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



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, preeclampsia.
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.





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.

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.

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.
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 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.






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
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.
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.
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 smokefree workplace.

MMWR 2008 57(20):549-52.
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
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
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
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.
› $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
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.
 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.
23.9%
20.8%
45.3 million current smokers in the US
45.7 million former smokers
MMWR 2007;56(44)1157-61.
18.0%
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.

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.
-restricted advertising
-counter-advertising
-less in movies and videos
-smoke-free ordinances
80
-reduced availability
70
60
50
Ever
Current 30 days
Current frequent
40
30
20
10
0
1991
1995
1999
2003
2007
-school-based tobaccouse prevention policies
and procedures
-higher price + excise tax
MMWR 2008;57(25):689-91.
-reduced parental and
societal prevalence
12-17yo
18-25yo
>25yo
25-44
45-64
>65
50
45
40
35
30
25
20
15
10
5
0
1985
1999
2000
2001
The World Almanac 2003. MMWR 2007;56(44):1157-61.
2006
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
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
1. Mackay
2000J3and
. 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.





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.
 “Stopping
smoking is easy.
I’ve done it a thousand times.”
Mark Twain

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
1. American Heart Association. 2. Taylor CB, et al. Ann Intern Med 1990;113;
post-MI were 20% more likely to survive 30 days, as
118-23. 3. Houston TK. Am J Med 2005;118:269-75.
well as 60 days, and one year3.

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

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
Alabama
MD 2005;41:1-3
. Treating Tobacco Use and
Dependence.

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.
1.
2.
3.
4.
Ask about smoking- every patient every
visit.
Advise one to quit- in a clear, strong
personalized manner.
Assess willingness to quit.
Assist those willing to quit.
If willing, offer medication, and provide or refer
for counseling or additional treatment. (1-800QUITNOW.)
2. If unwilling, provide interventions designed to
increase future quit attempts.
1.
Arrange for follow-up- if willing, at a week
a Treating
month.
If unwilling,
address
at
Fiore and
MC, et al.
tobacco
use and dependence:
clinical again
practice guideline.
next
visit.
Rockville
(MD):
US Dept Health Human Svcs Public Health Svc; 2008 Update.
5.
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
of medications
toPractice
Fiore
MC, et al. Treating Tobacco
Useuse
and Dependence:
2008 Update. Clinical
Guideline.
MD: USDHHS.
PHS. May 2008.
reduceRockville,
withdrawal
symptoms.


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.
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.

*Currently in clinical trials
70
60
% Quit
50
Nicotine +
Nortryptiline 75 mg
Nicotine + Placebo
40
30
20
10
Nicotine
18/79 (23%) vs 8/79
(10%); p=0.052
Nortryptiline
0
QD
30
60
90
120
150
180
Days since Quit Date
Prochazka A, et al. Arch Intern Med 2004;164:2229-33.
Clonidine also listed as
second-line treatment
in the guidelines.
p<.001
40.00%
35.00%
p<.001
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
Nicotine Buproprion Buproprion+
Placebo
NRT
Replacement
N=160
N=245
N=244
N=244
0.00%

150 mg po qd X 3 days, then 150 mg po bid.
Jorenby DE, et al: NEnglJMed 1999;340:685-91.

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
Picciotto
et al. Nicotine Tob Res. 1999; Suppl 2:S121-125.
partialMR,
agonist.
 Reduces the rewarding and reinforcing effects of

Varenicline
Adverse Effect
Placebo
% 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
*vomiting,
constipation,
diarrhea, flatulence, 12.0
dyspepsia.
8.1
.
Hays JT, and Ebbert JO. N Engl J Med 2008:359:2018-24
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, 1-800Hays
JT, and Ebbert JO.www.smokefree.gov.
N Engl J Med 2008:359:2018-24.
QUIT-NOW,

Express empathy.
2. Develop discrepancy.
3. Roll with resistance.
4. Support self-efficacy.
1.
Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice
Guideline. Rockville, MD: USDHHS. PHS. May 2008.
1.
2.
Relevance-personalize to disease states,
family situation.
Risks-
Acute- SOB, asthma flares, sinusitis, ulcers,
pregnancy.
2. Long-term- MI, CVA, COPD, cancer.
3. Environmental- spouse, infants, children.
1.
Rewards- health, taste, smell, money, selfimage, 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
Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice
support- do for yourself.
3.
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.
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


“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 flow.
› May cause spasm in these arteries.

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
Factors that increase the risk and severity
of atherosclerosis:
 Modifiable and un-modifiable

60
50
40
Male
Female
30
20
10
0
1965
1970
1975
1980
1985
1990
1995
45.4 million smokers in the US.
http://www.cdc.gov/nchs.
2000
2003
45
40
35
30
Non-high school grads
High school grads
Some college
College grads
25
20
15
10
5
0
1985
1999
2000
MMWR 2007;56(44):1157-61.
2001
2006

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.
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
Henningfield JE, et al. Drug Alcohol Depend 1993:33:23-9. Watkins SS, et al. Nicotine Tob Res
› Ventral tegmental area
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
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.
60
50.6
Quit Rate (%)
50
37.2
40
45.1
40.7
Placebo
30
20
11.6
12.4
10
Varenicline 0.5 mg bid
(N=253)
Varenicline 1.0 mg bid
(N=253)
All values p <0.0001
vs placebo
0
Weeks 4-7
Weeks 9-12
Oncken C. American College of Cardiology Meeting, March 8, 2005.

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
Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical
interventions.
Practice
Guideline. Rockville, MD: USDHHS. PHS. May 2008.

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
Fiore MC,
et al. Treating Tobacco
Use and Dependence:
2008 Update.
Clinical Practice
messages,
family
members).
Guideline.
Rockville,
MD: USDHHS.
PHS. May 2008.
1.
5.
6.
7.
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.
Tobacco use interventions are highly costeffective.
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.
Number of
Sessions
Number
of arms
Estimated Odds Ratio
(95% CI)
Estimated Abstinence
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
Smoking
2007 Goal:
Complete
cessation.
No exposure to
environmental
tobacco smoke.
Class I Recommendations
•Status of tobacco use should be asked at every
visit.
•Every tobacco user and family member who
smoke should be advised to quit at every visit.
•The tobacco user’s willingness to quit should be
NEW
assessed.
•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
NEW
home and work should be avoided.
Placebo
Rimonabant 5mg
Rimonabant 20mg
Percent 40
Abstinent
35
(%)
OR=2.2 - 95%CI=[1.374;3.456]
p=0.002
OR=2.0 - 95%CI=[1.296;3.046]
p=0.004
27.6
30
25
20
36.2
20.6
16.1
20.2
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.
 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'R.understanding
of the dangers of smoking and the
Alonso-Zaldivar
The Boston Globe. 10/22/08
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
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. Smokefree in 21 states.
 Restrictions in bars in only 20. Smoke-free in
13 states.
 As of 2003, 77% of US workers in a smokefree workplace.

MMWR 2008 57(20):549-52.