Download CORE MODULES & FORMS OF TOBACCO

Welcome to the February 2015
HHQI CardioLAN
Webinar
The Health Impact of
Tobacco Use and Cessation
Karen S. Hudmon, DrPH, MS, RPh
Professor of Public Health Pharmacy
Purdue University College of Pharmacy
Professor of Clinical Pharmacy
University of California San Francisco School of Pharmacy
This webinar was developed in collaboration
with the Rx for Change: Clinician-Assisted
Tobacco Cessation program
Copyright © 1999-2015 The Regents of the University of California.
All rights reserved.
http://rxforchange.ucsf.edu
“CIGARETTE SMOKING…
is the chief, single,
avoidable cause of death
in our society and the most
important public health
issue of our time.”
C. Everett Koop, M.D., former U.S. Surgeon General
All forms of tobacco are harmful.
TRENDS in ADULT SMOKING,
by SEX—U.S., 1955–2013
Trends in cigarette current smoking among persons aged 18 or older
60
Percent
50
17.8% of adults
are current
smokers
Males
40
30
20
Females
20.5%
15.3%
10
0
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
Year
69% want to quit
53% tried to quit in the past year
Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population
Survey; 1965–2013 NHIS. Estimates since 1992 include some-day smoking.
COMPOUNDS
in TOBACCO SMOKE
An estimated 4,800 compounds in tobacco smoke,
including 11 proven human carcinogens
Gases





Carbon monoxide
Hydrogen cyanide
Ammonia
Benzene
Formaldehyde
Particles





Nicotine
Nitrosamines
Lead
Cadmium
Polonium-210
Nicotine is the addictive component of tobacco products,
but it does NOT cause the ill health effects of tobacco use.
2014 REPORT of the
SURGEON GENERAL:
HEALTH CONSEQUENCES OF SMOKING
MAJOR DISEASE-RELATED CONCLUSIONS:

Cigarette smoking is causally linked to diseases of nearly all
organs of the body, diminished health status, and harm to the
fetus.



Additionally, smoking has many adverse effects on the body, such as
causing inflammation and impairing immune function.
Exposure to secondhand smoke is causally linked to cancer,
respiratory, and cardiovascular diseases, and to adverse effects
on the health of infants and children.
Disease risks from smoking by women have risen over the last
50 years and for many tobacco-related diseases are now equal to
those for men.
U.S. Department of Health and Human Services (USDHHS). (2014).
The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.
HEALTH CONSEQUENCES
of SMOKING

Cancers










Bladder/kidney/ureter
Blood (acute myeloid leukemia)
Cervix
Colon/rectum
Esophagus/stomach
Liver
Lung
Oropharynx/larynx
Pancreatic









Asthma
COPD
Pneumonia/tuberculosis
Chronic respiratory symptoms



Aortic aneurysm
Coronary heart disease
Cerebrovascular disease
Peripheral vascular disease
Reproductive effects

Pulmonary diseases

Cardiovascular diseases
Reduced fertility in women
Poor pregnancy outcomes (e.g.,
congenital defects, low birth weight,
preterm delivery)
Infant mortality
Other: cataract, diabetes (type 2), erectile
dysfunction, impaired immune function,
osteoporosis, periodontitis, postoperative
complications, rheumatoid arthritis
U.S. Department of Health and Human Services (USDHHS). (2014).
The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.
ANNUAL U.S. DEATHS ATTRIBUTABLE
to SMOKING, 2005–2009
Percent of all smokingattributable deaths
Cardiovascular & metabolic diseases
160,600
33%
Lung cancer
130,659
27%
Pulmonary diseases
113,100
23%
Second-hand smoke
41,280
9%
Cancers other than lung
36,000
7%
1,633
<1%
Other
TOTAL: >480,000 deaths annually
U.S. Department of Health and Human Services (USDHHS). (2014).
The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.
HEALTH CONSEQUENCES
of SMOKING

Cancers










Bladder/kidney/ureter
Blood (acute myeloid leukemia)
Cervix
Colon/rectum
Esophagus/stomach
Liver
Lung
Oropharynx/larynx
Pancreatic









Asthma
COPD
Pneumonia/tuberculosis
Chronic respiratory symptoms



Aortic aneurysm
Coronary heart disease
Cerebrovascular disease
Peripheral vascular disease
Reproductive effects

Pulmonary diseases

Cardiovascular diseases
Reduced fertility in women
Poor pregnancy outcomes (e.g.,
congenital defects, low birth weight,
preterm delivery)
Infant mortality
Other: cataract, diabetes (type 2), erectile
dysfunction, impaired immune function,
osteoporosis, periodontitis, postoperative
complications, rheumatoid arthritis
U.S. Department of Health and Human Services (USDHHS). (2014).
The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.
SMOKING and CARDIOVASCULAR
DISEASE: POSTULATED MECHANISMS

Smoking-induced atherogenesis

Endothelial injury/dysfunction

Lipids/lipid metabolism
Inflammation
 Thrombosis


Adverse effects on cardiovascular function


Increased oxygen demand
Decreased oxygen delivery
SMOKING CESSATION is a TREATMENT
for CARDIOVASCULAR DISEASE


Standard treatments reduce the risk of death
among patients with CVD by 15–35%
 Aspirin = 15%
 Beta blockers = 23%
 ACE inhibitors = 23%
 Statins = 29–35%
Among patients with CVD, cessation reduces the
risk of death by 36% and reduces the risk of
future cardiac events by 50%
IMPACT of SMOKING on
POST-OPERATIVE OUTCOMES
Quitting Smoking
Improves Surgical
Outcomes
Surgery Could
Promote Quitting
Smoking
TOBACCO CESSATION IMPROVES
SURGICAL OUTCOMES
Quitting reduces the incidence of:

Cardiovascular complications

Respiratory complications

Wound-related complications

Preoperative abstinence decreases the frequency of
intraoperative ischemia*
*Woehlck et al. (1999). Anesth Analg 89:856-860.
SMOKING CESSATION REDUCES
POSTOPERATIVE COMPLICATIONS
Percent

60
Control
50
Intervention
40
30
20

10
0
Any
Wound
Cardiac
120 orthopedic patient
randomized to tobacco
cessation intervention or
control, 6–8 weeks prior
to surgery
~80% of intervention
patients were able to
quit or reduce smoking
Type of Complication
Møller et al. (2002). Lancet 359:114–117.
2006 REPORT of the
SURGEON GENERAL:
INVOLUNTARY EXPOSURE to TOBACCO SMOKE


Second-hand smoke causes premature death and disease
in nonsmokers (children and adults)
Children:



There is no
safe level of
second-hand
smoke.
Increased risk for sudden infant death syndrome
(SIDS), acute respiratory infections, ear problems, and
more severe asthma
Respiratory symptoms and slowed lung growth if parents smoke
Adults:

Immediate adverse effects on cardiovascular system

Increased risk for coronary heart disease and lung cancer

Millions of Americans are exposed to smoke in their homes/workplaces

Indoor spaces: eliminating smoking fully protects nonsmokers

Separating smoking areas, cleaning the air, and ventilation are ineffective
U.S. Department of Health and Human Services (USDHHS). (2006).
The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General.
HEALTH CONSEQUENCES of
SMOKELESS TOBACCO USE
Periodontal effects



Gingival recession
Bone attachment loss
Dental caries
Oral leukoplakia
Cancer


Oral cancer
Pharyngeal cancer
Oral Leukoplakia
Image courtesy of Dr. Sol Silverman University of California San Francisco
ANNUAL SMOKING-ATTRIBUTABLE
ECONOMIC COSTS
Health-care
expenditures
$132.5 billion
Lost productivity costs
due to premature mortality
$156.4 billion
Total economic burden
of smoking, per year
$288.9 billion
0
50
100
150
200
250
300
Billions of US dollars
Societal costs: $19.16 per pack of cigarettes smoked
U.S. Department of Health and Human Services (USDHHS). (2014).
The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.
QUITTING:
HEALTH BENEFITS
Time Since Quit Date
Circulation improves,
walking becomes easier
Lung function increases
Excess risk of CHD
decreases to half that of a
continuing smoker
Lung cancer death rate
drops to half that of a
continuing smoker
Risk of cancer of mouth,
throat, esophagus,
bladder, kidney, pancreas
decrease
Lung cilia regain normal
function
2 weeks
to
3 months
1 to 9
months
Ability to clear lungs of mucus
increases
Coughing, fatigue, shortness of
breath decrease
1
year
5
years
Risk of stroke is reduced to that
of people who have never
smoked
after
15 years
Risk of CHD is similar to that of
people who have never smoked
10
years
SMOKING CESSATION:
REDUCED RISK of DEATH
Prospective study of 34,439 male British doctors
Mortality was monitored for 50 years (1951–2001)


Years of life gained
15
On average, cigarette
smokers die approximately
10 years younger than do
nonsmokers.
10
5
0
30
40
50
60
Among those who continue
smoking, at least half
will die due to a
tobacco-related disease.
Age at cessation (years)
Doll et al. (2004). BMJ 328(7455):1519–1527.
NICOTINE PHARMACOLOGY
NICOTINE DISTRIBUTION
Plasma nicotine (ng/ml)
80
Arterial
70
60
50
40
30
Venous
20
10
0
0
1
2
3
4
5
6
7
8
9
10
Minutes after light-up of cigarette
Nicotine reaches the brain within 10–20 seconds.
Henningfield et al. (1993). Drug Alcohol Depend 33:23–29.
NICOTINE
PHARMACODYNAMICS
Central nervous system




Pleasure
Arousal, enhanced vigilance
Improved task performance
Anxiety relief
Other



Appetite suppression
Increased metabolic rate
Skeletal muscle relaxation
(cont’d)
Cardiovascular system





 Heart rate
 Cardiac output
 Blood pressure
Coronary vasoconstriction
Cutaneous vasoconstriction
FACTORS CONTRIBUTING to
TOBACCO USE
Individual



Pharmacology
Sociodemographics
Genetic predisposition
Coexisting medical
conditions


Tobacco
Use
Environment



Tobacco advertising
Conditioned stimuli
Social interactions

Alleviation of withdrawal
symptoms
Weight control
Pleasure, mood
modulation
TOBACCO DEPENDENCE:
A 2-PART PROBLEM
Tobacco Dependence
Physiological
Behavioral
The addiction to nicotine
The habit of using tobacco
Treatment
Medications for cessation
Treatment
Behavior change program
Treatment should address the physiological
and the behavioral aspects of dependence.
CLINICAL PRACTICE GUIDELINE for
TREATING TOBACCO USE and DEPENDENCE


Update released May 2008
Sponsored by the U.S. Department of
Health and Human Services, Public Heath
Service with:





Agency for Healthcare Research and Quality
National Heart, Lung, & Blood Institute
National Institute on Drug Abuse
Centers for Disease Control and Prevention
National Cancer Institute
EFFECTS of CLINICIAN
INTERVENTIONS
Estimated abstinence at 5+
months
With help from a clinician, the odds of quitting approximately doubles.
30
n = 29 studies
Compared to patients who receive no assistance from a
clinician, patients who receive assistance are 1.7–2.2
times as likely to quit successfully for 5 or more months.
20
10
1.7
1.0
1.1
No clinician
Self-help
material
2.2
0
Nonphysician
clinician
Physician
clinician
Type of Clinician
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
Estimated abstinence rate
at 5+ months
The NUMBER of CLINICIAN TYPES
CAN MAKE a DIFFERENCE, too
30
n = 37 studies
Compared to smokers who receive assistance
from no clinicians, smokers who receive
assistance from two or more clinician types are
2.4–2.5 times as likely to quit successfully for 5 or
more months.
20
2.5
2.4
Two
Three or more
1.8
10
1.0
0
None
One
Number of Clinician Types
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
The 5 A’s
ASK
ADVISE
ASSESS
ASSIST
ARRANGE
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
The 5 A’s
(cont’d)
ARRANGE follow-up care
Number of sessions
Estimated quit rate*
0 to 1
12.4%
2 to 3
16.3%
4 to 8
More than 8
20.9%
24.7%
* 5 months (or more) postcessation
Provide assistance throughout the quit attempt.
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
BRIEF COUNSELING:
ASK, ADVISE, REFER
ASK
about tobacco USE
ADVISE
tobacco users to QUIT
REFER
to other resources
Patient receives assistance
from other resources, with
follow-up counseling arranged
ASSIST
ARRANGE
BRIEF COUNSELING:
ASK, ADVISE, REFER (cont’d)

Brief interventions have been shown to be effective

In the absence of time or expertise:

Ask, advise, and refer to other resources, such as
local group programs or the toll-free quitline
1-800-QUIT-NOW
This brief
intervention can be
achieved in less
than 1 minute.
TOBACCO DEPENDENCE:
A 2-PART PROBLEM
Tobacco Dependence
Physiological
Behavioral
The addiction to nicotine
The habit of using tobacco
Treatment
Medications for cessation
Treatment
Behavior change program
Treatment should address the physiological
and the behavioral aspects of dependence.
PHARMACOTHERAPY
“Clinicians should encourage all
patients attempting to quit to use
effective medications for tobacco
dependence treatment, except where
contraindicated or for specific
populations* for which there is
insufficient evidence of effectiveness.”
* Includes pregnant women, smokeless tobacco users, light smokers, and adolescents.
Medications significantly improve success rates.
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.
Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
NICOTINE REPLACEMENT
THERAPY (NRT)

Nicotine gum (Nicorette, generics)

Nicotine lozenge (Nicorette, Nicorette Mini, generics)

Transdermal nicotine patch (NicoDerm CQ, generics)

Nicotine nasal spray (Nicotrol NS)

Nicotine inhaler (Nicotrol Inhaler)
PLASMA NICOTINE CONCENTRATIONS
for NICOTINE-CONTAINING PRODUCTS
Cigarette
25
Moist snuff
Cigarette
Plasma nicotine (mcg/l)
20
Moist snuff
Nasal spray
15
Inhaler
10
Lozenge (2mg)
5
Gum (2mg)
0
1/0/1900
0
1/10/1900
10
1/20/1900
20
1/30/1900
2/9/1900
30
Time (minutes)
2/19/1900
40
2/29/1900
50
60
Patch
NON-NRT CESSATION AIDS
Zyban; generics

Bupropion SR (Zyban, generics)

Varenicline (Chantix)
LONG-TERM (6 month) QUIT RATES for
AVAILABLE CESSATION MEDICATIONS
30
28.0
Active drug
25
19.7
18.9
20
Percent quit
23.9
Placebo
16.3
17.1
15.9
15
11.8
10
10.0
9.8
11.5
12.0
Bupropion
Varenicline
9.1
8.4
5
0
Nicotine gum Nicotine patch
Nicotine
lozenge
Nicotine nasal
spray
Nicotine
inhaler
Data adapted from Cahill et al. (2012). Cochrane Database Syst Rev; Stead et al. (2012).
Cochrane Database Syst Rev; Hughes et al. (2014). Cochrane Database Syst Rev
COMPARATIVE DAILY COSTS
of PHARMACOTHERAPY
Average $/pack of cigarettes, $6.18
$9
$8
$7
$/day
$6
$5
$4
$3
$2
$1
$0
Trade
Generic
Gum
Lozenge
Patch
Nasal spray
Inhaler
$3.70
$1.90
$4.10
$2.66
$3.48
$1.52
$5.00
$8.51
Bupropion
SR
$6.22
$2.72
Varenicline
$8.24
SUMMARY


To maximize success, interventions should include
comprehensive counseling and one or more medications – with
follow-up care
Home health care provides a unique chance to capitalize on
“windows of opportunity”


Follow-up care for tobacco-related diseases

Establish formal “hand-off” protocol for cessation assistance

Continuation of in-patient cessation programs

Modification of home environments

Referrals to tobacco quitline or other resources
Enhance response to treatments

Post-operative wound healing, cancer care, other
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QUESTIONS?
Karen S. Hudmon, DrPH, MS, RPh
Professor of Public Health Pharmacy
Purdue University College of Pharmacy
Professor of Clinical Pharmacy
University of California San Francisco School of Pharmacy
Next CardioLAN Webinar
 Women’s Cardiovascular Health
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This material was provided by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health
Quality Improvement National Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of
Health and Human Services. The views presented do not necessarily reflect CMS policy. Publication number 11SOW-WV-HH-MMD-021915