Transcript ETS AND SMOKING CESSATION

PROMOTING SMOKING
CESSATION & SMOKEFREE HOMES IN
PEDIATRIC PRACTICE
Sophie J Balk MD
Professor of Clinical Pediatrics
AECOM
GOALS

To discuss
•Providing smoking
cessation counseling to
parents and teens who
smoke
•Promoting smoke-free
homes
OVERVIEW

Background
• Effects of active smoking
• Effects of secondhand smoke
• Why smokers don’t quit


Smoking cessation counseling,
pharmacotherapy
Bronx BREATHES, resources
The Life Cycle of the Effects
of Smoking on Health
Asthma
Otitis Media
Fire-related Injuries
SIDs
RSV/Bronchiolitis
Meningitis
Influences
to Start
Smoking
Childhood
Infancy
In utero
Adolescence
Nicotine Addiction
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. 1997;151:652
Adult Per Capita Cigarette Consumption and Major
Smoking and Health Events – U.S. 1900-2005
Broadcast
Ad Ban
1st Surgeon
General’s Report
5000
1st Great American
Smoke-out
Number of Cigarettes
End of WW II
OTC Nicotine
Medications
4000
Master
Settlement
Agreement
Fairness Doctrine
Messages on TV
and Radio
3000
1st Smoking-Cancer
Concern
2000
Non-Smokers Rights
Movement Begins Surgeon
General’s Report
on ETS
WWI
1000
Federal Cigarette
Tax Doubles
2009: Federal
Cigarette Tax
Increases and FDA
Regulation
Great Depression
0
1900
1910
1920
1930
1940
1950
1960
YEAR
Source: United States Department of Agriculture; Centers for Disease Control and Prevention
1970
1980
1990
?
2000
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
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 Adults—United States, 2007. MMWR November 14, 2008
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a2.htm
Adult Smoking in NYC
Down Almost 30% Since 2002
30
NYC
National
25.5
24.7
25
20
3-yr average
21.6
25.3
24.6
24
3-yr average
23.3
23.1
22.6
21.5
21.5
3-yr average
21.5
22.3
3-yr average
20.8
19.7
20.8
21.7
19.2
18.3
18.9
17.5
15
16.9
15.8
City and State
tax increases
Smoke-free
workplaces Free patch
programs and
creation of
Tobacco
Cessation
Centers
10
5
Media
Campaigns
0
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
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.
COSTS OF TOBACCO

2004: $193 billion annual health-related
economic losses1
• $96 billion mortality-related productivity losses
• >$97 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_statistics/fact_sheets/fast_facts/index.htm.
COMPARATIVE CAUSES
OF ANNUAL DEATHS, U.S.
450
Individuals
with mental
illness or
substance use
disorders
400
350
300
250
200
Sum of all these causes of death << tobacco alone
150
100
50
0
AIDS
Obesity
Suicide Smoking
Alcohol
Motor
Homicide
Vehicle
CDC Tobacco Information and Prevention Source: www.cdc.gov/tobacco
Drug
Induced
ANNUAL DEATHS ATTRIBUTABLE TO
CIGARETTE SMOKING: US, 2000 - 2004
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/data_statistics/
Factsheets/tobacco_related_mortality.htm#. September 2006
The Life Cycle of the Effects
of Smoking on Health
Asthma
Otitis Media
Fire-related Injuries
SIDs
RSV/Bronchiolitis
Meningitis
Influences
to Start
Smoking
Childhood
Infancy
In utero
Adolescence
Nicotine Addiction
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. 1997;151:652
SMOKING: FETAL EFFECTS






Spontaneous abortion
Stillbirth
Premature delivery
Low birth weight
Placental abruption
Neurodevelopmental effects
SECONDHAND SMOKE (SHS)

SHS
•smoke exhaled by smoker
•smoke released from a
smoldering cigarette

SHS = ETS (Environmental
Tobacco Smoke)
SHS

~4000 chemicals
• Irritants/systemic toxicants:
Hydrogen cyanide, SO2
• Reproductive toxicants: CO,
nicotine
• Mutagens/Carcinogens:
Benzene, benzo[a]pyrene

SHS is a Class A Carcinogen
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
SHS & CHILDREN:
CLINICAL EFFECTS


Asthma: 202,300 episodes/year1
Bronchitis/pneumonia (<18mo)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
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; 97:560-8.
3 – Farkas et al. Prev Med 1999.
SMOKING HAS SO MANY
BAD HEALTH EFFECTS –
WHY DON’T MORE
PEOPLE QUIT?
Tobacco advertising targeting women
Tobacco.org
Ads with Hip Hop Music Themes
Ad targeting African Americans
One of the two most popular brands among blacks in U.S.
www.tobaccofreekids.org
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
NICOTINE


Nicotine is a highly addictive
substance
Nicotine withdrawal
• Depressed mood
• Insomnia
• Irritability, anxiety, difficulty
concentrating
• Increased appetite
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
smoker’s
5 years: Stroke risk normalizes
10 years: Lung Ca death rate ½
smoker’s
http://www.cdc.gov/tobacco/sgr/sgr_2004/consumerpiece
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
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
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
www.surgeongeneral.gov/tobacco
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
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
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 >30 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)
Odds Ratio of Quitting
Odds Ratio of Quitting
Increases with Counseling
2.5
2.0
2.3
1.5
1.0
0.5
1.6
1.3
1.0
0.0
Co
n
3
tro
ls
M
in
.
310
M
>1
0
in
.
Total Contact Time
Quitting defined as abstinence for at least 5 months
Treating Tobacco Use and Dependence. US Public Health Service 2000
M
in
.
THE “5 A’S”
Ask
 Advise
 Assess
 Assist
 Arrange follow-up

System Implementation
“Ask”
Identify Tobacco Use /exposure to smoke
Document chart
“Advise”
“Assess”
“Assist”
“Arrange”
To Quit
willingness to quit
with quitting
Follow-up
Referrals
NYS Quitline
Fax to Quit
Individual/Group
Counseling &
Pharmacotherapy
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
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
PHARMACOTHERAPY

FDA-approved
• Bupropion SR*
*Rx needed
• Nicotine gum
• Nicotine inhaler*
• Nicotine lozenge
• Nicotine nasal spray*
• Nicotine patch
• Varenicline (Chantix)*
PHARMACOTHERAPY
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
NYS Smokers' Quitsite
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
Clinical Guideline, 2008 & Shiffman, et al,
2002
“A-A-R-P”





Practical alternative to the 5 A’s
Ask
Advise
Refer to Quitline/Fax-to-quit
Consider recommending or
prescribing Pharmacotherapy
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
Clinical Guidelines, 2000
“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
HARM REDUCTION:
REDUCING EXPOSURE

Promoting smoke-free homes
• Use if the smoker isn’t 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.
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_sheets/youth_data/tobacco_use/index.htm
TREATING ADOLESCENTS

NRT is safe in adolescents

Little evidence that NRT and Bupropion are
effective in adolescents

Safety & efficacy of varenicline not
established < 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
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
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
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
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
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
Bronx BREATHES:
Support 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
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
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
Proportion of Smokers Using NYS Quitline
by Borough, 2009
(Self-referral vs. MD-referral)
7.00
6.00
Call-in (Self-referred)
Referral by Physician (MD, etc)
% of Total Smokers
5.00
4.00
5.45
3.00
2.00
2.51
2.04
3.07
2.24
1.00
0.72
26%
0.67
0.00
Bronx
Manhattan
0.26
Brooklyn
0.52
Staten Island
0.13
Queens
Borough
Source: New York City Community Health Survey 2008 (Data checked 1/11/10) and New York State Quitline Services (Data checked
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.
NRT Distribution among
Fax-to-Quit Callers
100.00%
99.74%
90.00%
100.00%
94.13%
% of FTQ Registrants Receiving NRT
80.00%
83.54%
70.00%
60.00%
50.00%
50.17%
40.00%
30.00%
20.00%
10.00%
0.00%
Bronx
Manhattan
Brooklyn
Staten Island*
Queens
Borough
Source: New York City Community Health Survey 2008 (Data checked 1/11/10) and New York State Quitline Services (Data checked
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.