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PROMOTING SMOKING CESSATION

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* The NY State Quitline is an excellent resource which provides educational material, local referrals, and individualized telephone counseling. – PowerPoint PPT presentation

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Title: PROMOTING SMOKING CESSATION


1
PROMOTING SMOKING CESSATION SMOKE-FREE
HOMES IN PEDIATRIC PRACTICE
  • Sophie J Balk MD
  • Professor of Clinical Pediatrics
  • AECOM

2
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3
GOALS
  • To discuss
  • Providing smoking cessation counseling to parents
    and teens who smoke
  • Promoting smoke-free homes

4
OVERVIEW
  • Background
  • Effects of active smoking
  • Effects of secondhand smoke
  • Why smokers dont quit
  • Smoking cessation counseling, pharmacotherapy
  • Bronx BREATHES, resources

5
The Life Cycle of the Effects of Smoking on Health
Asthma Otitis Media Fire-related Injuries
Influences to Start Smoking
SIDs RSV/Bronchiolitis Meningitis
Childhood
Infancy
Adolescence
Nicotine Addiction
In utero
Adulthood
Low Birth Weight Stillbirth
Cancer Cardiovascular Disease COPD
Aligne CA, Stodal JJ. Tobacco and children An
economic evaluation of the medical effects
of parental smoking. Arch Pediatr Adolesc Med.
1997151652
6
Adult Per Capita Cigarette Consumption and Major
Smoking and Health Events U.S. 1900-2005
Source United States Department of Agriculture
Centers for Disease Control and Prevention
7
SCOPE OF THE PROBLEM
  • 19.8 of adults smoke (2007) -
    43.4 million people
  • Kentucky 28.3
  • West Virginia 27
  • New York 18.9
  • New Jersey 17.2
  • Connecticut 15.5
  • California 14.3
  • Utah 11.7

State-Specific Prevalence and Trends in Adult
Cigarette Smoking - US, 1998-2007
http//www.cdc.gov/mmwr/preview/mmwrhtml/mm5809a1
.htm
8
SMOKERS CHARACTERISTICS
  • 21.3 of men 18.4 of women
  • Ethnicity
  • Indian/Native 36.4
  • Non-Hispanic white 21.4
  • Non-Hispanic black 19.8
  • Hispanic 13.3
  • Asian 9.6
  • Highest rates among poor, less educated

Cigarette Smoking Among AdultsUnited States,
2007. MMWR November 14, 2008 http//www.cdc.gov/
mmwr/preview/mmwrhtml/mm5745a2.htm
9
Adult Smoking in NYCDown Almost 30 Since 2002
Source National smoking rates obtained from
National Health Interview Survey (NHIS) and
Morbidity and Mortality Weekly Report (MMWR) on
Cigarette Smoking Among Adults 1993-2008. New
York City smoking rates obtained from New York
City Community Health Survey 2008.
10
COSTS OF TOBACCO
  • 2004 193 billion annual health-related economic
    losses1
  • 96 billion mortality-related productivity losses
  • gt97 billion excess med expenditures
  • 5.5 million Years of Potential Life Lost
    annually2
  • 443,000 deaths/year3 - 1 in 5 deaths2
  • 1,200/day

1-Treating Tobacco Use and Dependence 2008.
2-Annual Smoking-attributable Mortality, Years
of Potential Life Lost, and Productivity
Losses-US,1997-2001. MMWR 7/1/05 www.cdc.gov/mmwr/
preview/mmwrhtml/mm5425a1.htm. 3-Smoking and
Tobacco Fast Facts. www.cdc.gov/tobacco/data_stat
istics/fact_sheets/fast_facts/index.htm.
11
COMPARATIVE CAUSES OF ANNUAL DEATHS, U.S.
CDC Tobacco Information and Prevention Source
www.cdc.gov/tobacco
12
ANNUAL DEATHS ATTRIBUTABLE TO CIGARETTE SMOKING
US, 2000 - 2004
13
TOBACCO AND HEALTH
  • 43 million adult smokers
  • Smoking will result in death for half of all US
    smokers alive today
  • Adults who smoke die 13 14 years earlier than
    nonsmokers
  • 6.4 million youth will die prematurely from
    smoking if current trends continue

Tobacco-related mortality. www.cdc.gov/tobacco/dat
a_statistics/ Factsheets/tobacco_related_mortality
.htm. September 2006
14
The Life Cycle of the Effects of Smoking on Health
Asthma Otitis Media Fire-related Injuries
Influences to Start Smoking
SIDs RSV/Bronchiolitis Meningitis
Childhood
Infancy
Adolescence
Nicotine Addiction
In utero
Adulthood
Low Birth Weight Stillbirth
Cancer Cardiovascular Disease COPD
Aligni CA, Stodal JJ. Tobacco and children An
economic evaluation of the medical effects
of parental smoking. Arch Pediatr Adolesc Med.
1997151652
15
SMOKING FETAL EFFECTS
  • Spontaneous abortion
  • Stillbirth
  • Premature delivery
  • Low birth weight
  • Placental abruption
  • Neurodevelopmental effects

16
SECONDHAND SMOKE (SHS)
  • SHS
  • smoke exhaled by smoker
  • smoke released from a smoldering cigarette
  • SHS ETS (Environmental Tobacco Smoke)

17
SHS
  • 4000 chemicals
  • Irritants/systemic toxicants Hydrogen cyanide,
    SO2
  • Reproductive toxicants CO, nicotine
  • Mutagens/Carcinogens Benzene, benzoapyrene
  • SHS is a Class A Carcinogen

18
SHS EFFECTS IN ADULTS
  • Known effects
  • Lung cancer - 3,400 deaths/yr
  • Ischemic heart disease - 46,000 deaths/yr
  • Higher risk of
  • Breast cancer
  • Nasal sinus cancer
  • California Air Resources Board.
    Environmental Tobacco Smoke SRB Approved Report.
    June 24, 2005. ftp//ftp.arb.ca.gov/carbis/regact/
    ets2006/app3exe.pdf

19
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20
SHS CHILDREN CLINICAL EFFECTS
  • Asthma 202,300 episodes/year1
  • Bronchitis/pneumonia (lt18mo)2
  • 150,000 - 300,000 cases
  • 7,500 15,000 hospitalizations
  • 136 212 deaths
  • OM 790,000 visits/year1
  • SIDS 430 deaths/year1

1-California Air Resources Board. June 2005.
ftp//ftp.arb.ca.gov/carbis/regact/ets2006/app3exe
.pdf 2-Health Effects of Exposure to
Environmental Tobacco Smoke. The Report of the
California Environmental Protection Agency,
1997
21
SHS CLINICAL EFFECTS
  • Exposed children more likely to have respiratory
    complications with general anesthesia1
  • Children living with smokers are at greater risk
    for injury and death from house fires2
  • Children living with smokers are more likely to
    become smokers themselves3
  • 1 - Koop CE, Anesthesiology 1998 88 1141-2.
  • 2 Difranza JR, Lew RA. Pediatrics 1996
    97560-8.
  • 3 Farkas et al. Prev Med 1999.

22
SMOKING HAS SO MANY BAD HEALTH EFFECTS WHY
DONT MORE PEOPLE QUIT?
23
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24
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25
Tobacco advertising targeting women
Tobacco.org
26
Ads with Hip Hop Music Themes
Ad targeting African
Americans One of the two most popular brands
among blacks in U.S.
27
NICOTINE
  • Effects
  • Increases concentration
  • Promotes memory recall
  • Improves psychomotor performance, alertness,
    arousal
  • Increases pain endurance
  • Decreases anxiety and tension
  • Decreases hunger pains, promotes weight loss

28
NICOTINE
  • Nicotine is a highly addictive substance
  • Nicotine withdrawal
  • Depressed mood
  • Insomnia
  • Irritability, anxiety, difficulty concentrating
  • Increased appetite

29
BENEFITS OF CESSATION
  • After 20 minutes HR drops
  • 12 hours Blood CO normalizes
  • 2 12 wks Better lung function
  • 1 year added CHD risk ½ smokers
  • 5 years Stroke risk normalizes
  • 10 years Lung Ca death rate ½ smokers

http//www.cdc.gov/tobacco/sgr/sgr_2004/consumerpi
ece
30
HELPING SMOKERS QUIT
  • US Public Health Service1
  • Clinicians should assess smoking status at every
    visit
  • Smoking cessation advise should be given
    routinely
  • AAP Pediatricians should give cessation advice
    to parents who smoke2,3,4

1- Treating Tobacco Use and Dependence 2008. 2-
AAP Ctte on Environmental Health, 1997. 3 AAP
Ctte on Substance Abuse, 2001
31
WHY FOCUS ON PARENTS?
  • 15 million US children live with a smoker
  • Pediatricians may be the only clinicians a parent
    visits
  • Most smokers want to quit
  • Most parents are receptive to counseling by
    pediatricians1

1 - Frankowski BL, Weaver SO, Secker-Walker RH.
Pediatrics 1993 91 296-300
32
INTERVENING WITH PARENTS WHO SMOKE
  • Interventions during clinic visits or
    hospitalizations increase parents' interest in
    stopping smoking, quit attempts, quit rates
  • Giving parents information about SHS reduces
    childhood SHS exposure and may reduce parental
    smoking rates

Treating Tobacco Use and Dependence 2008 update
33
www.surgeongeneral.gov/tobacco
34
TREATING TOBACCO USE AND DEPENDENCE
  • Tobacco dependence is a chronic condition
  • Nicotine is an addictive substance
  • Effective treatments exist
  • Treatments are cost-effective
  • Systems changes important

35
COUNSELING
  • Brief counseling is effective
  • Intensive counseling is better
  • Repeated brief interventions are appropriate
  • Standard of care identify and document tobacco
    use status, provide evidence-based treatments to
    every tobacco user

36
EFFICACY OF TOBACCO COUNSELING INTERVENTIONS
  • Brief counseling
  • 3-10 minutes
  • Targets smokers who are willing, unwilling, and
    those who recently quit
  • Intensive counseling
  • Total clinician-client time gt30 minutes with at
    least 4 sessions
  • Usually coordinated by tobacco dependence
    specialists

Dose response between number of clinician types
offering counseling and cessation success
(Fiore et al., 2008)
37
Odds Ratio of Quitting Increases with Counseling
Quitting defined as abstinence for at least 5
months
Treating Tobacco Use and Dependence. US Public
Health Service 2000
38
THE 5 AS
  • Ask
  • Advise
  • Assess
  • Assist
  • Arrange follow-up

39
System Implementation
Ask Identify Tobacco Use /exposure to smoke
Document chart
Advise To Quit
Assess willingness to quit
Assist with quitting
Arrange Follow-up
Referrals
NYS Quitline Fax to Quit
Individual/Group Counseling Pharmacotherapy
40
SMOKERS QUITLINES
  • Adjunct to office counseling
  • Professional, evidence-based, ongoing counseling
    services
  • Effective in helping adults quit1
  • Available in many states and through national
    quitline network
  • (1-800-QUITNOW)

1 Fiore, JAMA 2008
41
PHARMACOTHERAPY
  • Smokers trying to quit should be encouraged to
    use pharmacotherapy except under special
    circumstances
  • Medical contraindications
  • Not recommended for pregnant women, adolescents,
    light smokers, smokeless tobacco users

Fiore, JAMA 2008
42
PHARMACOTHERAPY
  • FDA-approved
  • Bupropion SR Rx needed
  • Nicotine gum
  • Nicotine inhaler
  • Nicotine lozenge
  • Nicotine nasal spray
  • Nicotine patch
  • Varenicline (Chantix)

43
PHARMACOTHERAPY
44
NRT NICOTINE REPLACEMENT THERAPY
  • Reduces cravings
  • Steady dose (patch) absorbed through the skin
  • Self-administered (gum, lozenge, inhaler, spray)
    absorbed through nasal/oral mucosa
  • Proven to increase quit rates
  • Safer way to get nicotine
  • Nicotine does not cause cancer

45
Effectiveness of Medications
  Odds ratio Abstinence rates
Placebo 1.0 13.8
Varenicline 3.1 33.2
Nicotine nasal spray 2.3 26.7
Nicotine patch 2.3 26.6
Nicotine gum 2.2 26.1
Nicotine inhaler 2.1 24.8
Bupropion SR 2.0 24.2
Nicotine lozenge 2 mg 4 mg 2.0 2.8 24.2/14.2 23.6/10.2
46
A-A-R-P
  • Practical alternative to the 5 As
  • Ask
  • Advise
  • Refer to Quitline/Fax-to-quit
  • Consider recommending or prescribing
    Pharmacotherapy

47
PREVENTING RELAPSE
  • Most relapses - first 3 months
  • Provide relapse prevention interventions to
    smokers who have recently quit
  • Congratulate patient
  • Discuss health benefits of cessation
  • Discuss threats to maintaining abstinence

48
THIRDHAND SMOKE
  • Toxins remain after the cigarette is extinguished
  • Even when smoke is not visible
  • Particulate matter deposited in a layer onto
    surfaces
  • In loose household dust
  • Volatile compounds that off gas for days,
    weeks, months
  • Children especially susceptible

Winickoff JP et al. Pediatrics 2009
49
HARM REDUCTION REDUCING EXPOSURE
  • Promoting smoke-free homes
  • Use if the smoker isnt ready to quit
  • Providing counseling and written materials
    successful1,2,3,4
  • Rules prohibiting household smoking shown to
    reduce SHS exposure5,6

1 - Hovell et al. Chest 1994. 2 Wahlgren et al.
Chest 1997. 3 Hovell et al. BMJ 2000. 4
Emmons et al. Pediatrics 2001. 5 Wakefield et
al. Am J Prev Med 1995. 6 Biener et al. Prev
Med 1997.
50
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51
ADOLESCENTS SMOKING
  • Tobacco industry targets the young
  • Children teens constitute the
  • majority of all new smokers
  • 20 of HS students
    6 of MS students smoke1
  • 80 of adult smokers tried their
  • first cigarette by age 18
  • Smoking cessation messages
  • methods are essential

1 www.cdc.gov/tobacco/data_statistics/fact_sheet
s/youth_data/tobacco_use/index.htm
52
TREATING ADOLESCENTS
  • NRT is safe in adolescents
  • Little evidence that NRT and Bupropion are
    effective in adolescents
  • Safety efficacy of varenicline not established
    lt 18 years
  • Counseling doubles long-term teen abstinence
    compared to usual care or no Rx
  • Adolescent smokers are identified and counseled
    to quit in 33 55 of MD visits
  • Assess teen tobacco use, counsel, F/U

Treating Tobacco Use and Dependence 2008
53
SYSTEMS INTERVENTIONS
  • Office systems needed to facilitate
    identification and treatment of smokers
  • Health system administrators, insurers and
    purchasers are encouraged to develop systems and
    policies to promote smoking cessation

54
OFFICE SYSTEM CHANGES
  • Implement tobacco user identification system
  • Add smoking status to vital signs
  • Tobacco use sticker
  • Provide staff education
  • Dedicate staff to tobacco treatment

55
SUMMARY
  • Tobacco is a major health threat
  • Clinicians must intervene consistently
  • Counseling and pharmacotherapy are effective
    treatments
  • All smokers should be offered consistent
    treatments
  • Promoting smoke-free homes is important for all
    families
  • Pediatricians can play an important role in
    counseling parents and teens

56
Bronx BREATHES Mission Resources
Barbara Hart, MPA Project Manager David
Lounsbury, PhD Co-Investigator Shadi Nahvi, MD,
MS Co-Investigator Claudia Lechuga, MS
Research Associate Hal Strelnick, MD Principal
Investigator Shaniyya Pinckney Academic Detailer
Bronx-Einstein Alliance for Tobacco-free Health
57
Bronx BREATHES Mission
  • Smoking is the leading preventable cause of
    illness and death in the Bronx and United States.
  • Bronx BREATHES works with the health care
    community to help Bronx residents quit smoking.
  • As one of 19 statewide Tobacco Cessation Centers,
    Bronx BREATEHS aims to
  • Provide Tobacco Control technical assistance
    training to health care institutions providers
    in the Bronx
  • Assist health care institutions with the design
    implementation of tobacco control policy
    treatment practices
  • Identify and promote direct cessation services
    located in the Bronx
  • Increase the number of Bronx residents who use
    the services of the NYS Smokers Quitline

58
Bronx BREATHESSupport Services for Clinicians
  • Training follow-up for providers
  • Design implementation of systems to
  • Identify monitor tobacco users at each patient
    visit
  • Foster patient referral to smoking cessation
    services (e.g., local support groups, NYSDOH
    Quitline
  • Incorporate tobacco control in EMR

59
Patient Referral Services Telephone Counseling
  • NYS Quitline 1-866-NY-QUITS
  • Services
  • Free telephone counseling in English, Spanish
    several other languages
  • Free NRT
  • Referrals to local counseling cessation
    programs
  • Free educational materials
  • Efficacy of Quitlines
  • Multiple calls OR 1.41 (1.27-1.57) increase in
    successful quit attempts
  • Efficacy for long term cessation
  • Effective at reaching racial/ethnic minority
    smokers

Stead et al., Cochrane Library, 2007
60
NYS Fax-to-Quit Referral Service
  • Available in paper online forms
  • Provider-referred patients are contacted by
    Quitline services offered the same services as
    above
  • Progress report sent back to you

61
Proportion of Smokers Using NYS Quitline by
Borough, 2009(Self-referral vs. MD-referral)
26
Source New York City Community Health Survey
2008 (Data checked 1/11/10) and New York State
Quitline Services (Data checked 1/4/10). All
estimates are weighted to the NYC adult
population per Census 2000 and rounded to the
nearest thousand. Referral denotes all patients
registered through Fax-to-Quit Paper or On-line
Service.
62
NRT Distribution among Fax-to-Quit Callers
Source New York City Community Health Survey
2008 (Data checked 1/11/10) and New York State
Quitline Services (Data checked 1/4/10). All
estimates are weighted to the NYC adult
population per Census 2000 and rounded to the
nearest thousand. Nicotine Replacement Therapy
(NRT) includes distribution of Nicotine Patch or
Nicotine Gum only. Staten Island figures
include distribution to Medicaid NRT recipients.
63
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