SMOKING IN THE ELDERLY POPULATION

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SMOKING IN THE ELDERLY POPULATION THEORY
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1. THE PROBLEM2. BENEFITS OF SMOKING
CESSATION3. STRATEGIES FOR SMOKING CESSATION
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IL PROBLEMA
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SMOKING IN THE ELDERLY POPULATION

• There are 1 billion, 100 million smokers in the
  world
• 1/3 of the population over the age of 15 smokes
• In developed states 42 of men and 24 of women
  smoke
• In Italy 30 of the population smokes. 29.1 of
  men and 19.2 of women 13-14 million people
  (adjusted prevalence estimates for WHO member
  states, tobacco survey 2005)
• Smoking causes about 90,000 deaths per year
• Smoking tobacco causes 85-90 of lung cancers
• One in six deaths in Italy are due to smoking and
  every day 246 people die because of smoking

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The WHO EPIDEMIC Tobacco epidemic death
toll(WHO Mpower report 2008) Dr Margaret Chan,
WHO Director-General

• 100 million deaths in the 20th century
• 5.4 million deaths per year
• Without urgent action, it is predicted that there
  will be more than 8 million deaths a year by 2030
• Of these more than 80 will be in developing
  countries
• 1 billion deaths are predicted for the 21st
  century

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PASSIVE SMOKING

• Passive smoking is also a risk, not only from
  cigarette smoke but from stoves and gas or
  kerosene cookers which raise levels of nitrogen
  oxide.
• Low socio-economic status is associated with
  higher prevalence of Chronic Obstructive
  Pulmonary Disease (COPD) compared to the general
  population with the seriousness of health
  problems increasing as the standard of living
  conditions falls.
• A diet poor in antioxidants (fruit and
  vegetables) and the abuse of alcohol seem to be
  correlated with a higher risk of developing COPD.
  
• (Smoking and Respiratory Illnesses, Risk Score
  Cards for COPD and Lung Tumours, Zuccaro, Viegi,
  Porta et al.)

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PASSIVE SMOKING(WHO Mpower report 2008)

• Every year in the USA, passive smoking is
  responsible for
• 3,400 deaths from lung cancer
• 46,000 deaths from heart disease
• 430 cases of cot death (SIDS)
• 24,500 low birth weights
• 71,900 premature births
• 200,000 increasingly serious asthma attacks among
  children

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COMPARISON WITH THE EFFECTS OF ENVIRONMENTAL
POLLUTIONShort-term effects on health of an
increase of 10-µg/m3 in the concentration of
PM10 a European study Royal College of
Physicians. Smoking and health now. London
Pitman Medical and Scientific Publishing, 1971.
Health outcome Estimated percentage increase in risk per 10 µg/m3 PM10 (95 confidence interval) Source Anderson HR et al. Meta-analysis of time series studies and panel studies of particulate matter (PM) and ozone (O3). Report of a WHO task group. Copenhagen, WHO Regional Office for Europe, 2004 Estimates risk in smokers (95 confidence interval) Source Royal College of Physicians. Smoking and health now. London Pitman medical and Sc. Publishing, 1971 Similar risk in rural area, Lancet 2003, 362 507
All-cause mortality 0.6 (0.40.8) 2.0-3.0
Mortality from respiratory diseases 1.3 (0.52.0) 2.9 (2.5-3.3)
Mortality from cardiovascular diseases 0.9 (0.51.3) 1.8 (1.7-1.9)
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THE ROLE OF COPD

• Most damage caused by smoking does not show at
  the first cigarette it takes years and sometimes
  decades
• COPD is a disease of the elderly population 90
  of COPD deaths occur after the age of 65
• Considering the increasingly important role of
  COPD in the elderly population (it is estimated
  that in 2020 it could become the third most
  common cause of death and the fifth most common
  cause of disability (Murray-Lopez, Global Burden
  of Disease Study, Lancet 3491498,1997)), early
  diagnosis of this smoking-related disease becomes
  fundamental, so that elderly people do not seek
  treatment only when they begin to have difficulty
  breathing.
• In this sense too society has changed, and since
  2005 the Consensus American Thoracic Society -
  European Respiratory Society have spoken of COPD
  as a curable disease!

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BENEFITS OF SMOKING CESSATION
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BENEFITS OF SMOKING CESSATION

• Evidence-based medicine shows that the only
  intervention capable of reducing morbidity and
  mortality in the short and long term is giving up
  smoking

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BENEFITS OF SMOKING CESSATION

• When no morbitity has occurred, often the elderly
  person is not motivated to give up until they are
  sick (cancer, stroke, or heart attack)
• So it is important to teach the elderly person
  that
• GIVING UP SMOKING
• Brings HEALTH BENEFITS
• Improves QUALITY OF LIFE
• Increases LIFE EXPECTANCY

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Above all, we need to give positive messages to
older peopleSOME GOOD REASONS TO STOP SMOKING
TO SAVE MONEY TO IMPROVE HEALTH BETTER SELF
ESTEEM BETTER GENERAL APPEARANCE SETTING A GOOD
EXAMPLE TO OTHERS
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THE BENEFITS(www.sfuma.it)

• Less than 30 minutes after the last cigarette,
  blood pressure and the temperature of hands and
  feet return to normal.
• After 8 hours levels of oxygen in the blood
  return to normal and levels of carbon monoxide
  are reduced.
• After 48 hours senses of taste and smell are
  increased and nerve endings begin to repair
  themselves.
• After 72 hours breathing becomes easier as lung
  capacity increases.
• After 1 week the risk of a heart attack is
  reduced, nicotine is eliminated from the body
  thus improving senses of taste and smell and
  reducing bad breath. Teeth and hair are shinier.
• Between 2 weeks and 3 months lung capacity
  increases by 300 and circulation improves,
  walking becomes easier, and you feel more
  energetic.

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THE BENEFITS(www.sfuma.it)

• Between 1 and 9 months a third of those who
  gained weight when quitting have regained their
  original weight. Lungs clean themselves more
  efficiently and the risk of infections is
  drastically reduced colds, coughs, tiredness and
  shortness of breath are also reduced.
• After 1 year the risk of a heart attack is halved
  and the risk of developing cancer begins to
  reduce.
• After 5 years the risk of lung cancer is reduced
  by 50 and that of a stroke is reduced to that of
  a non-smoker.
• After 10 years the likelihood of dying from lung
  cancer is equal to that of a non-smoker and the
  risk of other cancers is reduced (mouth, throat,
  pancreas, bladder, kidney and oesophagus).
  Precancerous cells are gradually replaced.
• After 15 years the principal indicators of risk
  have returned to normal.

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STRATEGIES FOR SMOKING CESSATION
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STRATEGIES PROPOSED BY THE WHO TO COMBAT THE
SMOKING EPIDEMIC (WHO Policy Recommendations
for Smoking Cessation and Treatment of Tobacco
Dependence) MPOWER

• Monitor tobacco use and prevention policies
• Protect people from tobacco smoke
• Offer help to quit tobacco use
• Warn about the dangers of tobacco
• Enforce bans on tobacco advertising,
• promotion and sponsorship, and
• Raise taxes on tobacco

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WHO STRATEGIES TO COMBAT THE SMOKING EPIDEMIC
(WHO Policy Recommendations for Smoking Cessation
and Treatment of Tobacco Dependence)

• Change the social climate and promote a
  supportive environment
• Promoting and integrating clinical best practices
  (behavioural and pharmacological)
• A surveillance, research and information approach
  that promotes the exchange of information and
  knowledge so as to increase awareness of the need
  to change social norms (Chapter I, Matrix 1,
  pages 7-10).

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WHO STRATEGIES TO COMBAT THE SMOKING
EPIDEMIC(WHO Policy Recommendations for Smoking
Cessation and Treatment of Tobacco Dependence)

• Ex-smokers can serve as role models in
  encouraging quitting, and can provide social
  support to individuals who are attempting to
  quit.
• They also may reflect an environment in which
  quitting is a greater priority.

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WHO STRATEGIES TO COMBAT THE SMOKING
EPIDEMIC(WHO Policy Recommendations for Smoking
Cessation and Treatment of Tobacco Dependence)

• The success of these interventions depends on
  their synergistic use in a broader context of
  comprehensive tobacco control programmes

• motivation,
• advice and guidance,
• counselling,
• telephone and internet support,
• appropriate pharmaceutical aids

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HOW TO ENCOURAGE CHANGE
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HOW TO ENCOURAGE CHANGEMINIMAL ADVICE

• (Agency for Health Care Policy and Research
  (AHCPR) guidelines for smoking dissuasion JAMA
  1996, 257/16 1270-80)

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HOW TO ENCOURAGE CHANGE

• Monitor the smoker who has given up through
  repeated check-up visits these have proven
  useful in reinforcing motivation to continue
  giving up (Ann Intern Med 1989, 110 648-652)
• Without behavioural treatment, attempts to give
  up smoking are generally short-lived and present
  a high risk of dropping out within a year (Eur J
  Cancer 1994, 30A/2 253-263).

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MOTIVATIONAL TOOLSEACH PERSON HAS A DIFFERENT
SITUATIONEACH PERSON NEEDS A DIFFERT
STRATEGY(DOTT. FORZA G., Stop smoking clinic,
Az. Ospedaliera Padova)
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Consider the idea of changingSTRATEGY EVALUATE
THE PROs AND CONs (DECISION SCALES)
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Obtain and Maintain the changeSTRATEGY MAINTAIN
SELF-EFFECTIVENESS
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THE LANGUAGE OF CHANGE

• Open questions
• Reflective listening
• Synthesise
• Confirm
• Bring out self-motivating affirmations

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Fagerström test for nicotine dependence
(Heatherton TF, Kozlowski LT, Frecker RC,
Fagerstrom KO. The Fagerstrom Test for Nicotine
Dependence A revision of the Fagerstrom
Tolerance Questionnaire. British Journal of
Addictions 1991861119-27)

• Your nicotine dependence level is .
• 0-2 very low
• 3-4 low
• 5 medium
• 6-7 high
• 8-10 very high
• less than 5 points your level of dependence is
  still low. You should act before it grows
• 5 7 points you have a moderate level of
  dependence, if you dont quit as soon as possible
  your dependence will grow until you are seriously
  addicted. Act now to free yourself from your
  nicotine dependence.
• more than 7 points your level of dependence is
  high. You dont control your smoking, it
  controls you! When you decide to give up it
  would be good to speak to your doctor about a
  nicotine/drug based subsitute treatment to help
  you give up.

• 1. After waking do you smoke a cigarette within
• 60 minutes (0)
• 31-60 minutes (1)
• 6-30 minutes (2)
• within 5 minutes (3)
• 2. Do you find it difficult to stay in places
  where smoking is banned?
• No (0)
• Yes (1)
• 3. Which cigarette would you find it hardest to
  give up?
• The first in the morning (1)
• Any other (0)
• 4. How many cigarettes do you smoke per day?
• 10 or less (0)
• 11-20 (1)
• 21-30 (2)
• 31 or more (3)
• 5. Do you smoke more in the first hour after
  waking than during the rest of te day?
• No (0)
• Yes (1)

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Motivational Questionnaire(H.Mondor, Paris) The
following questionaire evaluates the motivation
of a person who sees their doctor about giving up
( www.fumo.it)

• 9. I am pregnant/my partner is pregnantYes No
• 10. I have small childrenYes No
• 11. I am in a good mood at the momen
• Yes No
• 12. I usually finish what I start
• Yes No
• 13. I am usually calm and relaxedYes No
• 14. My wieght is usually stable
• Yes No
• 15. I want to improve my quality of life
• Yes No

• 1. I decided to give up spontaneouslyYes No
• 2. I have already given up for more than a
  weekYes No
• 3. I dont have any problems at work at the
  momentYes No
• 4. I donthave any family problems at the
  momentYes No
• 5. I want to free myself from my addictionYes No
• 6. I do sport or I intend to do sportYes No
• 7. I want to be in better physical shapeYes No
• 8. I want to look after my physicla
  appearanceYes No

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HOW TO ENCOURAGE CHANGE

• Role of the doctor
• Get the patients history of smoking
• Help the patient to better understand the
  needs/motives behind their smoking in order to
• Find ways of developing different responses to
  these needs and motives
• Provide Information
• Educational material for independent learning
• Emotional and psychological support
• And if necessary pharmaceutical support to help
  the patient to stop smoking.

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5 STEPS TO BEHAVIOUR CHANGE

• Fix a precise and meaningful date to give up
  smoking completely, with some weeks before for
  psychological preparation and informing friends,
  family and the doctor of the date so that they
  can provide support
• Keep a written smoking diary in order to
  identify the situations and times in which the
  impulse to smoke is strongest
• Identify alternative behaviours to respond to
  specific situations where the desire to smoke is
  strongest, preparing a distraction activity in
  order to reduce the stress of not smoking write
  a list of difficult situations and possible
  alternative behaviours can seem boring but is
  definitely useful in the long term.
• Get positive reinforcements in order to keep
  motivated write a list of reasons for giving up
  smoking, rewards for achievements and regular
  contact with friends who have already given up,
  marking off the days since giving up on a
  calendar.
• Consider any lapses as mistakes along the road
  and use them as a chance to better understand
  reasons for smoking and how to combat the desire
  more effectively next time.

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Smokers are more likely to succeed if they tackle
one problem at a time

• Smokers who fix a date to stop smoking, usually
  planning a 4 to 6 week strategy, then proved more
  determined in giving up smoking (Med Clin North
  Am 1992, 76 477-494).
• Smokers who manage to stop smoking for at least 2
  weeks are more likely to continue not smoking
  (JAMA 1988, 259 2883-9).
• Most relapses occur within 6 weeks after smoking
  cessation (J Clin Psych 1977, 27 455-6).

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Smokers are more likely to succeed if they tackle
one problem at a time

• Weight gain is a major obstacle in giving up
  smoking, especially in female smokers (Ann Behav
  Med 1989, 11 144-153).
• The commitment to preventing eventual weight gain
  related to smoking cessation (through diet
  therapy, etc) can reduce the current commitment
  to stop smoking (Am J Public Health 1992, 82
  1238-1243).

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SMART Objectives

• Diaphragmatic breathing
• Distraction techniques (from the thought of
  smoking)
• Resistant breathing
• (PEP mask)

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SMART Objectives

• Learning to breathe well over time
• How to slow breathing getting to know ones
  diaphragm

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SMART Objectives
Breathing resistance exercises (PEP mask)
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SMART Objectives
Distraction Techniques (from the thought of
smoking) (see www.quitguide.com)

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• PRACTICAL PART

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Practical Part (1)

• Activity in multidisciplinary groups
• Groups of approx. 10 people
• Three sets of 10 minutes (101010 minutes)
• One group leader for each group (a doctor, nurse,
  pharmacist or other expert)
• In each group two people are chosen to act out a
  dialogue between the doctor and patient/smoker
  using the script of the Motivational interview
  (available in the training toolkit).
• At the end of the interview the rest of the group
  comments on the stages, progression and
  conclusion that they saw, guided by the group
  leader (10 mins).

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Practical Part (2)

• They then discuss possible next steps, eg. plan a
  follow-up visit, and how these next steps can be
  planned with the patient (10 mins).
• The brochure Learning to Breathe Well With the
  Years is then handed out, which explains various
  techniques for supporting patients in giving up
  smoking, and participants discuss the contents
  (10 mins).

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The challenge for public health is to make
healthy choices the easy choices