Tanesha Lawrence, MD

1
PUT OUT THAT LIGHT! A day in the life of a Butt
Buster

• Tanesha Lawrence, MD
• Jo Applebaum, MPH
• New York Childrens Health Project
• Montefiore Medical CenterCommunity Pediatrics
• National Health Care for the Homeless Conference
• June 26, 2009

2
Who We Are
Childrens Hospital at Montefiore
Childrens Health Fund
Community Pediatric Programs
Center for Preventive Health and Special
Initiatives
New York Childrens Health Project
South Bronx Health Center for Children and
Families
3
New York Childrens Health Project (NYCHP)

• Established 1987
• Bureau of Primary Health Care (330h) grantee
• Serves children/families at 14 shelter sites
• 2008 Utilization
• 3,650 patients
• 12,750 visits
• 3.5 visits per patient

4
Stages of Change for a smoking cessation program

• Precontemplation/Contemplation
• Motivation
• Preparation
• Tools
• Action
• Components of the program
• Maintenance
• Sustaining the program

5
(No Transcript)
6
Tommy The Tobacco Tyrant
7
(No Transcript)
8
Motivation Tobacco mortality

• 1 cause of premature and preventable death in US
• 443,000 deaths/y due to first or second hand
  smoke
• 9 million deaths/y worldwide by 2020

Sources www.who.int www.cdc.gov
9
Motivation Tobacco mortality

• Leading causes of tobacco-related death
  (2000-2004)
• Lung cancer 125,522
• COPD 78,988
• Ischemic heart disease 80,005

CDC. Smokingattributable mortality, years of
potential life lost, and productivity
lossesUnited States, 2000-2001. MMWR
2008571226-1228.  
10
Motivation Perinatal effects

• 776 infant deaths/y (2000-2004)
• Causes
• Preterm delivery
• Low birth weight
• SIDS
• Stillbirth

CDC. Smokingattributable mortality, years of
potential life lost, and productivity
lossesUnited States, 2000-2001. MMWR
2008571226-1228.  
11
Motivation Second-hand smoke

• 49,400 deaths/y
• Lung cancer and ischemic heart disease
• Children
• Worsens asthma
• Increases risk of
• SIDS
• Lower respiratory tract infection
• Middle ear infection

www.cdc.gov/tobacco/data_statistics/fact_sheets/he
alth_effects/tobacco_related_mortality.htm
12
Third Hand Smoke

• Toxic particles remaining after secondhand smoke
  has cleared
• Contain carcinogens

13
(No Transcript)
14
Health benefits of quitting
20 minutes Heart rate drops 12 hours Carbon
monoxide levels drop to normal 2 days Ability to
smell and taste improve 23 weeks Circulation,
lung function improves 1 month Coughing and
shortness of breath decrease 1 year Heart
disease risk cut in half 5 years Stroke risk
that of a non-smoker 10 years Risk of lung cancer
death half that of a smoker 15 years Risk of
heart disease same as a non-smoker
www.nyc.gov/html/doh/html/smoke/smoke2-cess.shtml
3
15
Tobaccos Special Powers

• Nicotine
• Shape-shifter
• Universal appeal
• Powerful allies

16
NICOTINE HIGHLY ADDICTIVE!

• Pleasure
• Appetite suppression

• norepinephrine arousal, appetite suppression
• acetylcholine arousal, cognitive enhancement
• vasopressin memory improvement
• serotonin mood modulation, appetite suppression
• beta endorphin reduction of anxiety and tension
  

17

• Smoked tobacco
• Cigarettes
• Cigar
• Pipe

• Smokeless tobacco
• Snuff
• Chew
• Gutka

18
Smoked tobacco

• Cigarette
• -tobacco wrapped in paper or wrapped in any
  substance without
• tobacco

• Cigar
• -tobacco wrapped in paper or wrapped in any
  substance
• with
• tobacco

19
Cigarette

• Shorter fermentation process
• Wrapping more porous
• Lower pH
• must inhale to get tobacco
• Takes less time to smoke

20
Cigar (cont.)

• Higher carcinogenic potential
• -longer aging and fermentation process
• -cigar wrapping less porous
• -nicotine absorbed 2 ways
• mucous membranes due to high pH in tobacco
• inhaling smoke
• -takes longer to smoke

21
Dont be fooled

• Flavored
• Light/Ultralight
• Low-tar
• Menthol
• Little cigars

22
TobaccoUniversal Appeal

• 1.3 billion people worldwide use tobacco
• US 43.5 million smokers (2007)
• Adults 20
• High School age 20
• NYC 17 (2007)
• Education (some high school) 22
• Poverty (less than 200) 20

23
Allies

• Multibillion dollar tobacco corporations
• Media

24

• Myths about Smoking Cessation
• in Homeless Populations
• Why bother?

25
Why Bother?

• In US, 70 of smokers say they want to quit
  (2006)
• 19.2 million (44) attempted to quit
• In NYC, 68 of smokers attempted to quit (2007)
• Education (some high school) 69
• Income (less than 200) 72

26
Why Bother?

• Smoking prevalence in homeless populations
• 70 to 80
• Readiness to quit
• 26 to 76 thinking about quitting in next 6 mo
• Reasons for smoking
• Social acceptability
• Stress, boredom
• Counseling/medications (patch) effective
• Follow-up!

27
Plan of Attack
Clinical Practice Guideline Treating Tobacco Use
and Dependence 2008 Update

• 5 As
• Ask Identify and document tobacco use
• Advise Urge every tobacco user to quit
• Assess Willingness to make a quit attempt
• Assist Medications, counseling, motivation
• Arrange Schedule follow-up

Fiore MC, Jaén CR, Baker TB, et al. Treating
Tobacco Use and Dependence 2008 Update. Clinical
Practice Guideline. Rockville, MD U.S.
Department of Health and Human Services. Public
Health Service. May 2008.
28
Assess Stages of readiness to quit

• Precontemplation No problem/no plan to quit
  in next 6 mo
• Contemplation Aware of problem/thinking about
  quitting in next 6 mo
• Preparation Cutting down/intention to quit
  in next 30 d
• Action Quit smoking in past 6 mo
• Maintenance Relapse prevention (gt6 mo to
  several years after action)
• Termination No desire to restart

29
Advise by stage of readiness

• Pre/Contemplation
• 5 Rs
• Relevance
• Risks
• Rewards
• Roadblocks
• Repetition

• Preparation/Action
• Strategies Quit Plan
• Counseling
• Medications
• Education/information
• Group support

30
10 reasons to quit

• Live a healthier life
• Live a longer life
• Be free of addiction
• Improve the health of people around you
• Save money
• Feel better
• Improve your quality of life
• Have a healthy baby
• Improve sexual and reproductive health
• Stop smelling like an ashtray

www.nyc.gov/html/doh/html/smoke/smoke2-cess.shtml
3
31
Meta-analysis (2000) Effectiveness and estimated
abstinence rates for different types of formats
(58 studies)
Fiore MC, Jaén CR, Baker TB, et al. Treating
Tobacco Use and Dependence 2008 Update. Clinical
Practice Guideline. Rockville, MD U.S.
Department of Health and Human Services. Public
Health Service. May 2008.
32
Meta-analysis (2000) Effectiveness and estimated
abstinence rates for interventions by different
types of clinicians (29 studies)
Fiore MC, Jaén CR, Baker TB, et al. Treating
Tobacco Use and Dependence 2008 Update. Clinical
Practice Guideline. Rockville, MD U.S.
Department of Health and Human Services. Public
Health Service. May 2008.
33
Assist Medications

• Medications increase long-term abstinence rates
• Nicotine
• Nicotine patch
• Nicotine gum
• Nicotine lozenge
• Nicotine inhaler
• Nicotine nasal spray
• Non-nicotine
• Bupropion SR (Zyban, Wellbutrin)
• Varenicline (Chantix)

34
Meta-analysis (2000) Effectiveness and estimated
abstinence rates for medications counseling vs
meds alone (9 studies) and counseling alone (18
studies)
Meds/ Counseling
Meds
Meds/ Counseling
Counseling
35

• Would the Butt Busters accept this difficult
  mission?

36
NYCHP tobacco cessation program

• Tobacco cessation EHR template
• Provider Counseling
• Exhale for Life Group/Education workshops
• Health Promotion

37
Tobacco Cessation Template

• Implemented 4/2007
• Revised 4/2008, 1/2009
• Contents
• Tobacco use status
• Amount (category)
• Readiness to quit
• Cessation interventions
• Asthma

38
Tobacco cessation template results

• April 2007-October 2008 (18-mo period)
• 2000 patients queried about tobacco use
• ?18 y 93 queried
• ?11 y 86 queried
• 721 smokers identified
• 98 of smokers were ?18 y

39
NYCHP estimated smoking rate
42.3
16.9
18 y
40
Cigarettes per day

• 1-5/day 53
• 1-10/day 77
• Within 1 hour of waking 49

41
Readiness to Quit (initial)
18.9
40.5
37.6
97 assessed for readiness to quit
42
Tobacco Users and Asthma
Analysis of data 4/08-10/08 Smokers n 267
43
Provider Intervention
Analysis of data 4/08-10/08 Smokers n 267
44
Follow-up assessment

• 46 (26/56) decreased tobacco use
• 10 (4/42) increased readiness to quit
• 2 quit (hooray!)

Analysis of data 4/08-10/08 Smokers n 267
45

• Call in Reinforcements

46
Exhale for Life Group

• JulyDecember 2007
• 5 cycles at 2 shelters (N45)
• 4 sessions each cycle
• Health effects
• Quitting strategies
• Medications
• Stress management
• Variables measured
• Stage of readiness to quit
• Amount tobacco use

47
Exhale for Life Stage of readiness

• 47 (21/45) assessed 2 times
• 38 increased readiness to quit

48
Exhale for Life Tobacco use

• 31 (14/45) assessed 2 times
• 9/14 (64) reduced tobacco use
• 3 quit (hooray!)
• Overall
• 20 decreased
• 7 quit

49

• What other tactics will Butt Busters use in their
  war against tobacco?

50
Lessons Learned

• Smokers want to quit, including homeless
• Shelter administration buy-in critical
• Obligations, pressures, priorities
• Follow-up
• Self-selection bias
• Stress-health promotion model
• Usefulness of EHR

51
(No Transcript)
52
Questions?