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Cancer, Cardiovascular and Pulmonary Pathophysiology Linked to Tobacco


... from lung cancer is more than 22 times higher among men who smoke cigarettes, ... Injury begins when smoke causes lung tissue to become red and swollen. ... – PowerPoint PPT presentation

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Title: Cancer, Cardiovascular and Pulmonary Pathophysiology Linked to Tobacco

Cancer, Cardiovascular and Pulmonary
Pathophysiology Linked to Tobacco
  • Carlos Roberto Jaén, MD, PhD, FAAFP
  • Professor and Chairman
  • Family and Community Medicine
  • University of Texas Health Science Center
  • at San Antonio

  • Health consequences of smoking on cancer,
    cardiovascular and pulmonary diseases
  • Smoking cessation strategies that work!
  • Leading edge areas of research in primary care
    clinical settings

Health Consequences of Smoking on Cancer,
Cardiovascular and Respiratory Diseases
  • The 2004 Surgeons General Report

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  • Most cells in the body continually divide and die
    off in a very controlled way.
  • Some chemicals can interfere with the cell
    division process, causing a cancer to develop.
  • Cancer tends to leave the original location and
    spread through the body this is called
    metastasis. When the body cannot keep up with
    the growth of cancer, the patient dies.

  • Cancer is the second leading cause of death in
    the United States.
  • In 2003 it is estimated that more than half a
    million would die from cancer, more than 1500
    people a day.
  • The risk of dying from lung cancer is more than
    22 times higher among men who smoke cigarettes,
    and about 12 times higher among women who smoke
    cigarettes compared with never smokers.

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Cardiovascular Diseases
  • Heart disease and stroke are the first and third
    leading causes of death in the United States and
    are caused by smoking.
  • More than 61 million Americans suffer from some
    form of heart or blood vessel disease including
    high blood pressure, coronary heart disease,
    stoke and heart failure.

Cardiovascular Diseases
  • Nearly 2600 Americans die daily as a result of
    cardiovascular diseases or about one every 33
  • Most cases of these diseases are caused by
    atherosclerosis, a hardening and narrowing of the
  • Damage to arteries and blood clots that block
    blood flow can cause heart attacks or strokes.

Cardiovascular Diseases
  • Cigarette smoke damages the cells lining the
    blood vessels and heart.
  • The damaged tissue swells, and makes it hard for
    blood vessels to get enough oxygen to cells and
  • Cigarette smoke increases the risk of dangerous
    blood clots both by redness and swelling and by
    causing blood platelets to clump together.

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Pulmonary Diseases
  • Smokers have difficulty fighting infections well,
    these infections cause lung tissue injury that
    leads to chronic obstructive pulmonary disease
    (COPD), sometimes called emphysema and other
    pulmonary diseases.
  • People with COPD slowly start to die from lack of

Pulmonary Diseases
  • COPD is the fourth leading cause of death in the
    United States, accounting for about 100,000
    deaths a year.
  • About 90 of all deaths from COPD are
    attributable to cigarette smoking.
  • Most sudden respiratory illnesses are caused by
    viruses and bacteria. Smokers have a weaken
    immune system that has difficulty clearing these
    infections from the lungs.

Pulmonary Diseases
  • Chronic lung diseases are long lasting and affect
    the airways and the tiny sacs where oxygen is
    absorbed into the lungs.
  • Injury begins when smoke causes lung tissue to
    become red and swollen. This releases unwanted
    oxygen molecules that damage the lung. It also
    causes release of enzymes that can eat delicate
    lung tissue.

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  • Major cancers, cardiovascular and respiratory
    diseases are caused by tobacco use.
  • Is there experimental evidence that smoking
    cessation reduces mortality?
  • Are there effective treatments for smoking

The Lung Health Study
  • Randomized clinical trial of smokers with mild
    COPD treated with intense cessation intervention
    (12 two-hour sessions over 10 weeks)
  • Significant benefits of cessation at 14 ½ years
    of follow-up, even though only 22 quit in the
    intervention group vs. 5 in usual care group
  • First randomized trial to confirm prior
    epidemiological observations.

Anthonisen, N. R. et. al. Ann Intern Med
All-cause 14.5-year survival
Anthonisen, N. R. et. al. Ann Intern Med
Mortality rates at 14.5 years by cause and
smoking status
Anthonisen, N. R. et. al. Ann Intern Med
Smoking Cessation Strategies that Work!
  • Treating Tobacco Use and Dependence
  • US PHS Clinical Practice Guideline, June 2000

Major Findings and Panel
  • 1. Tobacco dependence is a chronic condition that
    often requires repeated intervention. However,
    effective treatments exist that can produce
    long-term or even permanent abstinence.

Major Findings and Panel Recommendations
  • 2. Because effective tobacco dependence
    treatments are available, every patient who uses
    tobacco should be offered one or more of these

Major Findings and Panel Recommendations
  • 3. It is essential that clinicians and health
    care delivery systems institutionalize the
    consistent identification, documentation, and
    treatment of every tobacco user seen in a health
    care setting.

Major Findings and Panel Recommendations
  • 4. Brief tobacco dependence treatment is
    effective, and every patient who uses tobacco
    should be offered at least brief treatment.

Major Findings and Panel Recommendations
  • 5. There is a strong dose-response relation
    between the intensity of tobacco dependence
    counseling and its effectiveness. Treatments
    involving person-to-person contact (via
    individual, group, or proactive telephone
    counseling) are consistently effective, and their
    effectiveness increases with treatment intensity
    (e.g., minutes of contact).

Major Findings and Panel Recommendations
  • 6. Three types of counseling and behavioral
    therapies were found to be especially effective
    and should be used with all patients attempting
    tobacco cessation
  • Provision of practical counseling
    (problem-solving/skills training)
  • Provision of social support as part of treatment
    (intra-treatment social support)
  • Help in securing social support outside of
    treatment (extra-treatment social support)

Major Findings and Panel Recommendations
  • 7. Numerous effective pharmacotherapies for
    smoking cessation now exist. Five first-line
    pharmacotherapies were identified that reliably
    increase long-term smoking abstinence rates
  • Bupropion SR
  • Nicotine gum
  • Nicotine inhaler
  • Nicotine nasal spray
  • Nicotine patch

Major Findings and Panel Recommendations
  • 7. Continued
  • Two second-line pharmacotherapies were identified
    as efficacious and may be considered by
    clinicians if first-line pharmacotherapies are
    not effective
  • Clonidine
  • Nortriptyline
  • Over-the-counter nicotine patches are effective
    relative to placebo, and their use should be

Major Findings and Panel Recommendations
  • 8. Tobacco dependence treatments are both
    clinically effective and cost-effective relative
    to other medical and disease prevention
    interventions. As such, insurers and purchasers
    should ensure that
  • All insurance plans include as a reimbursed
    benefit the counseling and pharmacotherapeutic
    treatments identified as effective in this
  • Clinicians are reimbursed for providing tobacco
    dependence treatment just as they are reimbursed
    for treating other chronic conditions

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Clinical Interventions
  • The 5 As for patients willing to make a quit
  • The 5 Rs for patients unwilling to make a quit
    attempt at this time
  • Relapse prevention for patients who have recently
  • Intensive interventions should be provided
    when possible
  • Health care administrators, insurers, and
    purchasers should institutionalize guideline

The 5 As For Patients Willing to Quit
  • ASK about tobacco use
  • ADVISE to quit
  • ASSESS willingness to make a quit attempt
  • ASSIST in quit attempt
  • ARRANGE for followup

Elements of a Counseling Intervention
  • Quit date
  • Set a stop date, preferably within 2 weeks
  • Starting on the quit date, total abstinence is
  • Review Past quit experiences
  • Anticipate triggers or challenges in upcoming

Elements of a Counseling Intervention (contd)
  • Alcohol
  • Since alcohol can cause relapse, the patient
    should consider limiting/abstaining from alcohol
    while quitting
  • Other smokers in the household
  • Quitting is more difficult when there is another
    smoker in the household
  • Patients should encourage housemates to quit with
    them or not smoke in their presence

The 5 Rs to Enhance Motivation for Patients
Unwilling To Quit
  • RELEVANCE Tailor advice and discussion to each
  • RISKS Discuss risks of continued smoking
  • REWARDS Discuss benefits of quitting
  • ROADBLOCKS Identify barriers to quitting
  • REPETITION Reinforce the motivational message
    at every visit

  • Smoking cessation reduces mortality and effective
    smoking cessation interventions exist.
  • Are smokers receiving these interventions in
    primary care practices?
  • What can we do to get more smokers to quit?

Why Primary Care Practice?
  • Most Americans see a primary care clinician
  • 60 of outpatient visits
  • Teachable moments
  • Relationships developed over time and multiple

Competing Demands Theory
  • Many worthwhile services compete with each other
    for time on the agenda of primary care patient
  • When primary care clinicians are not doing one
    activity under scrutiny (e.g. smoking cessation
    counseling), they may be doing something else
    that is more compelling.
  • Jaén CR, Stange KC, Nutting PA. The competing
    demands of primary care A model for the delivery
    of clinical preventive services. J Fam Pract.
    1994 38166-171.
  • Stange KC, Fedirko T, Zyzanski SJ, Jaén CR.
    How do family physicians prioritize delivery of
    multiple preventive services? J Fam Pract.
    1994 38231-237.

Two Studies in Primary Care
  • The Direct Observation of Primary Care Study
  • Funded by the National Cancer Institute (NCI)
  • Prevention and Competing Demands
  • Funded by Agency for Healthcare Research and
    Quality (AHRQ) formerly known as AHCPR

Direct Observation of Primary Care (DOPC)
  • Methods
  • More than 4000 visits directly observed by
    research nurses.
  • Every 20 seconds up to 15 behaviors coded
  • 80 family practice offices in Northeastern Ohio
  • Patient exit surveys, chart reviews, practice
  • Multimethod (qualitative and quantitative
  • Stange KC, Zyzanski SJ, Jaén CR, et al.
    Illuminating the black box A description of
    4454 patient visits to 138 family physicians. J
    Fam Pract, 1998 46377-389.

Time for Tobacco Counseling
  • 55 of well care visits
  • 22 of illness visits
  • More common during visits for tobacco-related
    chronic illness vs. a visit for another chronic
    disease (32 vs. 17)
  • Average duration of advice lt1.5 minutes
  • Context of counseling not clear
  • Jaén CR, Crabtree BF, Zyzanski SJ, Stange KC.
  • Making time for tobacco counseling. J Fam Pract,

Prevention and Competing Demands Study
  • Multimethod comparative case study design in
  • Direct observation and detailed descriptions of
    1624 encounters by 50 clinicians in 18 family
  • In-depth interview of clinicians, office staff
    and community residents
  • Medical record review
  • Patient exit questionnaires

Crabtree BF. Miller WL. Stange KC. Understanding
practice from the ground up. Journal of Family
Practice. 50(10)881-7, 2001
Competing Demands and Tobacco Counseling
  • Hierarchy of taken missed opportunities
  • Good (5As) counseling 21
  • Competing demands 24
  • Failure in a non-smoking related visit 27
  • Failure in a smoking-related visit 25
  • Failure in a health maintenance visit 2
  • Guidelines to counsel every visit unrealistic
  • Systems individual approaches are needed
  • Jaén CR, McIlvain H, Pol L, Phillips RL, Flocke
    SA, Crabtree BF. Tailoring tobacco counseling to
    the competing demands in the clinical encounter.
    J Fam Pract, 2001 50859-863.

New Theoretical Framework
  • Complexity Science
  • Primary care practices are complex adaptive
    systems facing the need to respond to internal
    and external uncertainty and surprise. For
    clinicians and practices to maximize their
    ability to proactively evolve as they respond to
    uncertainty and surprise, they need to understand
    that their practices are nonlinear systems and
    create the time and space for learning and

Crabtree BF. Primary Care Practices are Full of
Surprises Health Care Management Review.
28(3)279-83, 2003 Miller WL. McDaniel RR Jr.
Crabtree BF. Stange KC. Practice jazz
understanding variation in family practices using
complexity science. Journal of Family Practice
50(10)872-8, 2001
Future Research
  • How can primary care practices be re-designed to
    improve delivery of smoking cessation services?
  • What can be done to improve integration of
    community and practice resources?
  • How can counseling for multiple health behaviors,
    e.g. tobacco and problem drinking be integrated
    into practices?

A RWJF and AHRQ Program
In Summary
  • Research regarding the treatment of tobacco use
    and dependence continues to grow exponentially.
  • The challenge is translation - ensuring that the
    practice of treating tobacco use and dependence
    keeps pace with the research.