Transcript SOGC`s Violence Against Women Program

Risk Factors for Smoking in the
EMR Region
Kawkab Shishani, BSN, PhD
The Hashemite University
Epidemiology of Diabetes & Other NonCommunicable Diseases
Alexandria, Egypt
6-13th January 2009
Petra: Jordan’s Wonder of the World
Objectives
1. Describe the scope of the problem
2. Examine smoking among selected populations
3. Differentiate between forms of tobacco use
4. Discuss why smoking is harmful
5. Value WHO position on tobacco control
6. Summarize how health care professionals can provide
the leadership in tobacco control
Question
Why is it important to study smoking ?
1. Smoking is the chief avoidable risk factor for NCDs
2. Smoking Affects the progression of NCDs (> complications)
3. Unlike the other risk factors such as physical activity and
nutrition that affects only those who do not comply to them,
smoking affects smoker as well as those around
Why Do Farmers Grow Tobacco?
The wealth generated by leaf tobacco production helps
to improve quality of life and attracts educational,
health and social facilities in, otherwise, relatively
impoverished, rural areas.
International tobacco growers association
http://www.tobaccoleaf.org/about_itga/index.asp?op=1
Scope of the Problem
 1,3 billion smokers:
 80% in developing countries
 20% in developed countries
 The number is expected to increase by 1.7 per cent
annually
 By 2030, 80% of deaths due to tobacco will occur in
developing countries
Scope of the Problem
 Most cigarettes consumed worldwide are
international brands
 As smoking rates in the US and Europe is
declining, new markets are needed
 Globalization made it easy for companies to
access new markets internationally (Asia, Africa,
Middle East)
Smoking: Men and Women
 Global smoking (M: 4> F)
↑ in smoking rates in F > M
 Ratio of smoking M: F
 Developed countries 3:1
 Developing countries 7:1
Smoking: Men and Women
80
70
60
50
40
Men
Women
30
20
10
0
EMR country profilehttp://www.emro.who.int/TFI/CountryProfile
Smoking: Men and Women
 50%-66% of women use “light”
 Addiction in M>F
 Biological responses to nicotine
differ between M & F
Smoking in women is reinforced by
less nicotine than in men (Perkins et al., 1991)
Female Smoking & Low Birth Weight
35
30
25
20
Female smoking
15
LBW
10
5
0
www.globalheathfactt.org
Smoking: Youth
WHO (2007). Sifting the evidence: Gender and tobacco control
Youth Smoking in EMR
EMR country profilehttp://www.emro.who.int/TFI/CountryProfile
Smoking: Youth
I can't stop smoking. I am addicted to cigarettes.
 Parent (father smokes)
 Access to cigarettes
 Peer pressure
 Experimentation
 Imitating adults
Smoking: Health Professionals
80
70
60
50
Smoker
Former
Non-smoker
40
30
20
10
0
EMR
Egypt
Jordan
Saudia
GHPS: Jordan
Characteristic
Once started clinical work smoking
Decreased
Stayed the same
Increased
Do you want to quit smoking
Yes
No
Have you ever tried to quit
Yes
No
How many times you tried to quit
1-3 times
Women
% (n)
Men
% (n)
Total
% (n)
34.4 (32)
35.5 (33)
30.1 (93)
24.2 (104) 26.1(136)
34.7 (149) 34.9 (182)
41.0 (176) 39.1 (204)
62.0 (54)
37.9 (33)
52.0 (216) 53.8 (270)
48.0 (199) 46.2(232)
54.9 (50)
45.1 (41)
61.9 (255) 60.6(305)
38.1 (157) 39.4 (198)
77.8 (28)
37.9 (161) 74.4 (189)
GHPS: Jordan
Learning Need Assessment
Nurses Physician Total
%
s
%
%
Cigarettes and argileh are both addicting
37.2
52.2
41.9
Taught in classes about dangers of smoking
65.7
72.5
67.6
Discuss in any of your classes why people smoke
53.1
60.6
55.1
Ever received any formal training in smoking cessation
35.9
26.6
32.3
Provide materials to support smoking cessation to
patients
54.2
63.6
56.9
Forms Of Tobacco Use
 Waterpipe
 Cigarettes
 Chewing
Second Hand Smoking
 At home:
 Smoking around children
 Children prepare waterpipe for parents
 Cultural issues
 Public places (hospitals, buses, taxis,..)
Waterpipe: The Emerging Epidemic
Myths:
 It is safe alternative for cigarettes
 Chemicals filtered by the water (bubbling)
 Not addictive; can quit anytime
 Highest rates are in MENA
Social practice (Café employees)
Children smoke with their parents
(WHO study group , 2005)
(Asfar et al. BMC Public Health 2005)
(Shihadeh., 2004)
(Maziak et al., 2004)
Waterpipe: The Emerging Epidemic
 Nicotine in 1 head of unflavored tobacco = 70
regular cigarettes;
 Flavored tobacco = 20cigarettes
 A single smoking session: 2.25 mg nicotine, high
levels of arsenic, cobalt, chromium, and lead
 Cotinine levels are almost the same among
waterpipe and cigarette smokers
(Shihadeh, 2003)
(Bacha, Salameh, Waked , 2007)
Chemicals Produced From Smoking
 Nicotine
 Tar
 Carbon monoxide
 Benzopyrene
 Cyanide hydrogen
How Does Nicotine Work?
From Benowitz N. Nicotine Addiction. Primary Care 1999; 26(3):611-31
Why Nicotine Matters
Short term effect
Long term effect
Tobacco Dependence: A Chronic Disease
 The long delay between the onset of smoking
and associated morbidities
 70% of the smokers want to quit Unsuccessful
 44% tried to quit
 Only 7% succeed
Tobacco Dependence: A Chronic Disease
 A Chronic disease model:
 Long term nature
 Minimum number achieve permanent
abstinence
 Periods of relapse and remissions
 No ideal intervention
 Emphasis on education and counseling (same
like in DM, HTN)
(US Department of Health and Human Services, 2008)
WHO Efforts to Control Tobacco Use
(FCTC)
Price and tax measures
 Protection from exposure to tobacco smoke
 Educational and public awareness programmes
Promoting the cessation of tobacco use
 Sales to and by minors
 Research, surveillance and exchange
Where Do We Go From Here?
 Monitoring tobacco use to provide accurate
tracking of epidemiological data about the extent of
tobacco exposure (GTSS)
 Report morbidities associated with smoking
 Public Education (media, curricula)
 Health Insurance companies (reimburse tobacco
dependence treatments)
Why Do We Need A Plan in EMR
 Lack of human resources (experienced in tobacco
control
 Lack of adequate studies on hazards of smoking
 Research encouragement (Funding)
http://www.emro.who.int/tfi/CountryProfile-Part6.
2008 Update
Identifying Tobacco Users
Meta-analysis (1996): Impact of having a tobacco use status
identification system in place on abstinence rates among patients who
smoke (n = 3 studies) a
Screening System
No screening system in place to identify
smoking status (reference group)
Screening system in place to identify smoking
status
a Go
Estimated Abstinence
Rate (95% C.I.)
3.1
6.4 (1.3–11.6)
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
Physicians Should Advise
Meta-analysis (1996): Effectiveness of and estimated abstinence rates for advice to
quit by a physician (n = 7 studies)a
a Go
Advice
Estimated Abstinence Rate
No advice to quit (reference group)
7.9
Physician advice to quit
10.2 (8.5–12.0)
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
Intensity of Clinical Interventions
Meta-analysis (2000): Effectiveness of and estimated abstinence rates for various
intensity levels of session length (n = 43 studies) a
Level of Contact
No Contact
Estimated Abstinence Rate (95% C.I.)
10.9
Minimal counseling
(< 3 minutes)
13.4 (10.9–16.1)
Low-intensity counseling
(3-10 minutes)
16.0 (12.8–19.2)
Higher intensity counseling
(> 10 minutes)
22.1 (19.4–24.7)
a Go
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
Total Amount Of Contact Time
Meta-analysis (2000): Effectiveness of and estimated abstinence rates for total amount
of contact time (n = 35 studies) a
Total Amount of
Contact Time
Estimated Abstinence Rate (95% C.I.)
No minutes
11.0
1–3 minutes
14.4 (11.3–17.5)
4–30 minutes
18.8 (15.6–22.0)
31–90 minutes
26.5 (21.5–31.4)
91–300 minutes
28.4 (21.3–35.5)
> 300 minutes
25.5 (19.2–31.7)
a Go
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
Number Of Sessions
Meta-analysis (2000): Effectiveness of and estimated abstinence rates for number of
person-to-person treatment sessions (n = 46 studies)a
Number of Sessions
Estimated Abstinence Rate (95% C.I.)
0–1 session
12.4
2–3 sessions
16.3 (13.7–19.0)
4–8 sessions
20.9 (18.1–23.6)
> 8 sessions
24.7 (21.0–28.4)
a Go
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
Type of Clinician
Meta-analysis (2000): Effectiveness of and estimated abstinence rates
for interventions delivered by different types of clinicians (n = 29
studies)a
Type of Clinician
No clinician
Estimated Abstinence Rate (95% C.I.)
10.2
Self-help
10.9 (9.1–12.7)
Non-physician clinician
15.8 (12.8–18.8)
Physician clinician
19.9 (13.7–26.2)
a Go
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
Type of Clinician
Meta-analysis (2000): Effectiveness of and estimated abstinence
rates for interventions delivered by various numbers of clinician
types (n = 37 studies)a
Number of Clinician Types
No clinician
Estimated Abstinence Rate (95% C.I.)
10.8
One clinician type
18.3 (15.4–21.1)
Two clinician types
23.6 (18.4–28.7)
Three or more clinician types
23.0 (20.0–25.9)
a Go
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
Formats of Psychosocial Treatments
Meta-analysis (2000): Effectiveness of and estimated abstinence rates for various
types of formats (n = 58 studies) a
Format Number
Estimated Abstinence Rate (95%
C.I.)
No format
10.8
Self-help
12.3 (10.9–13.6)
Proactive telephone counseling
13.1 (11.4–14.8)
Group counseling
13.9 (11.6–16.1)
Individual counseling
16.8 (14.7–19.1)
a Go
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
Quitlines
Meta-analysis (2008): Effectiveness of and estimated abstinence rates for quitline
counseling compared to minimal interventions, self-help, or no counseling (n = 9
studies) a
Intervention
Minimal or no counseling or self-help
Quitline counseling
Estimated Abstinence
Rate (95% C.I.)
10.8
12.7 (11.3–14.2)
Meta-analysis (2008): Effectiveness of and estimated abstinence rates for
quitline counseling and medication compared to medication alone (n = 6 studies ) a
Intervention
Medication alone
Medication and quitline counseling
a Go
Estimated Abstinence
Rate (95% C.I.)
23.2
28.1 (24.5–32.0)
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
Treatment Elements
Meta-analysis (2000): Effectiveness of and estimated abstinence rates for various types of
counseling and behavioral therapies (n = 64 studies)a
Type of Counseling and
Behavioral Therapy
No counseling/behavioral therapy
Estimated Abstinence Rate
(95% C.I.)
11.2
Relaxation/breathing
10.8 (7.9–13.8)
Contingency contracting
11.2 (7.8–14.6)
Weight/diet
11.2 (8.5–14.0)
Cigarette fading
11.8 (8.4–15.3)
Negative affect
13.6 (8.7–18.5)
Intratreatment social support
14.4 (12.3–16.5)
Extratreatment social support
16.2 (11.8–20.6)
Practical counseling
(general problem solving/ skills training)
16.2 (14.0–18.5)
Other aversive smoking
17.7 (11.2–24.9)
Rapid smoking
19.9 (11.2–29.0)
a Go
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
Treatment Elements
Meta-analysis (2000): Effectiveness of and estimated abstinence rates for acupuncture
(n = 5 studies)a
Treatment
Placebo
Acupuncture
a Go
Estimated Abstinence Rate (95% C.I.)
8.3
8.9 (5.5–12.3)
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
Combining Counseling & Medication
Meta-analysis (2008): Effectiveness of and estimated abstinence rates for the combination of counseling and
medication vs. medication alone (n = 18 studies) a
Treatment
Medication alone
Estimated Abstinence Rate (95% C.I.)
21.7
Medication and counseling
27.6 (25.0–30.3)
Meta-analysis (2008): Effectiveness of and estimated abstinence rates for the number of sessions of counseling in
combination with medication vs. medication alone (n = 18 studies) a
Treatment
Estimated Abstinence Rate (95% C.I.)
0–1 session plus medication
21.8
2–3 sessions plus medication
28.0 (23.0–33.6)
4–8 sessions plus medication
26.9 (24.3–29.7)
More than 8 sessions plus medication
32.5 (27.3–38.3)
Meta-analysis (2008): Effectiveness of and estimated abstinence rates for the combination of counseling and medication vs.
counseling alone (n = 9 studies) a
Treatment
Counseling alone
Medication and counseling
a Go
Estimated Abstinence Rate (95% C.I.)
14.6
22.1 (18.1–26.8)
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
First-Line Medications
Meta-analysis (2000): Effectiveness of and estimated abstinence rates for various types of counseling and behavioral
therapies (n = 64 studies)a
Estimated Abstinence Rate
(95% C.I.)
Medication
Placebo
13.8
Monotherapies
Varenicline (2 mg/day)
Nicotine Nasal Spray
33.2 (28.9–37.8)
26.7 (21.5–32.7)
High-Dose Nicotine Patch ( > 25 mg) (These included both standard or long-term duration)
26.5 (21.3–32.5)
Long-Term Nicotine Gum (> 14 weeks)
Varenicline (1 mg/day)
Nicotine Inhaler
Clonidine
Bupropion SR
Nicotine Patch (6–14 weeks)
Long-Term Nicotine Patch (> 14 weeks)
Nortriptyline
Nicotine Gum (6–14 weeks)
26.1 (19.7–33.6)
25.4 (19.6–32.2)
24.8 (19.1–31.6)
25.0 (15.7–37.3)
24.2 (22.2–26.4)
23.4 (21.3–25.8)
23.7 (21.0–26.6)
22.5 (16.8–29.4)
19.0 (16.5–21.9)
Combination Therapies
Patch (long-term; > 14 weeks) + ad lib NRT (gum or spray)
Patch + Bupropion SR
Patch + Nortriptyline
Patch + Inhaler
Patch + Second generation antidepressants (paroxetine, venlafaxine)
Medications not shown to be effective
Selective Serotonin Re-uptake Inhibitors (SSRIs)
Naltrexone
a Go
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
36.5 (28.6–45.3)
28.9 (23.5–35.1)
27.3 (17.2–40.4)
25.8 (17.4–36.5)
24.3 (16.1–35.0)
13.7 (10.2–18.0)
7.3 (3.1–16.2)
Nicotine Lozenge
Relative Effectiveness of Medications
Medication
Estimated Odds Ratio (95% C.I.)
Nicotine Patch (reference group)
1.0
Monotherapies
Varenicline (2 mg/day)
1.6 (1.3–2.0)
Nicotine Nasal Spray
1.2 (0.9–1.6)
High-Dose Nicotine Patch ( > 25 mg) (standard or long-term)
1.2 (0.9–1.6)
Long-Term Nicotine Gum (> 14 weeks)
1.2 (0.8–1.7)
Varenicline (1 mg/day)
1.1 (0.8–1.6)
Nicotine Inhaler
1.1 (0.8–1.5)
Clonidine
1.1 (0.6–2.0)
Bupropion SR
1.0 (0.9–1.2)
Long-Term Nicotine Patch (> 14 weeks)
1.0 (0.9–1.2)
Nortriptyline
0.9 (0.6–1.4)
Nicotine Gum
0.8 (0.6–1.0)
Combination Therapies
Patch (long-term; > 14 weeks) + NRT (gum or spray)
1.9 (1.3–2.7)
Patch + Bupropion SR
1.3 (1.0–1.8)
Patch + Nortriptyline
0.9 (0.6–1.4)
Patch + Inhaler
1.1 (0.7–1.9)
Second generation antidepressants & Patch
1.0 (0.6–1.7)
Medications not shown to be effective
Selective Serotonin Re-uptake Inhibitors (SSRIs)
0.5 (0.4–0.7)
Naltrexone
0.3 (0.1-0.6)
a Go
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
Precessation NRT Use
Meta-analysis (2008): Effectiveness of and abstinence rates for smokers not willing to
quit (but willing to change their smoking patterns or reduce their smoking) after
receiving NRT compared to placebo (n = 5 studies) a
Intervention
Placebo
Nicotine replacement
(gum, inhaler, or patch)
a Go
Estimated Abstinence Rate
(95% C.I.)
3.6
8.4 (5.9–12.0)
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
Use of Over-the-Counter Medications
Meta-analysis (2000): Effectiveness of and estimated abstinence rates for OTC
nicotine patch therapy (n = 3 studies) a
OTC Therapy
Placebo
OTC nicotine patch therapy
a Go
Estimated Abstinence Rate
(95% C.I.)
6.7
11.8 (7.5–16.0)
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
Systems Evidence
Meta-analysis (2008): Effectiveness of and estimated abstinence rates for clinician training
(n = 2 studies) a
Intervention
No Intervention
Estimated Abstinence
Rate (95% C.I.)
6.4
Clinician Training
12.0 (7.6–18.6)
Meta-analysis (2008): Effectiveness of clinician training on rates of providing treatment (“Assist”)
(n = 2 studies) a
Intervention
No Intervention
Clinician Training
Estimated Rate
(95% C.I.)
36.2
64.7 (53.1–74.8)
Meta-analysis (2008): Effectiveness of clinician training combined with charting on asking about smoking status (“Ask”)
(n = 3 studies) a
Intervention
No Intervention
Training and charting
a Go
Estimated Rate
(95% C.I.)
58.8
75.2 (72.7–77.6)
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
Systems Evidence
Meta-analysis (2008): Effectiveness of training combined with charting on setting a quit date (“Assist”) (n = 2 studies) a
Intervention
No Intervention
Estimated Abstinence
Rate (95% C.I.)
11.4
Training and charting
41.4 (34.4–48.8)
Meta-analysis (2008): Effectiveness of training combined with charting on providing materials (“Assist”) (n = 2 studies) a
Intervention
No Intervention
Training and charting
Estimated Rate
(95% C.I.)
8.7
28.6 (24.3–33.4)
Meta-analysis (2008): Effectiveness of training combined with charting on arranging for follow-up (“Arrange”) (n = 2
studies) a
Intervention
No Intervention
Training and charting
a Go
Estimated Rate
(95% C.I.)
6.7
16.3 (11.8– 22.1)
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
Providing Treatment as a Covered
Benefit
Meta-analysis (2008): Estimated rates of quit attempts for individuals who received tobacco use interventions as a covered
health insurance benefit (n = 3 studies) a
Treatment
Individuals with no covered benefit
Individuals with the Benefit
a Go
Estimated Quit Attempt
Rate (95% C.I.)
30.5
36.2 (32.3–40.2)
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
Treatment in Children & Adolescents
Meta-analysis (2008): Effectiveness of and estimated abstinence rates for counseling
interventions with adolescent smokers (n = 7 studies) a
Adolescent Smokers
Estimated Abstinence Rate
(95% C.I.)
Usual care
6.7
Counseling
11.6 (7.5–17.5)
a Go
to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.
5 As
A1. Ask—Systematically identify all tobacco users at every
visit
A2. Advise—Strongly urge all tobacco users to quit
A3. Assess—Determine willingness to make a quit attempt
A4. Assist—Aid the patient in quitting (provide counseling
and medication)
A5. Arrange—Ensure follow-up contact
Treating Tobacco Use and Dependence: 2008 Update” Clinical Guideline
Elements of Counseling
Problem solving/ skills training
Recognize danger situations –
Develop coping skills- Identify and practice coping
Provide basic information
Supportive treatment
Encourage the patient in the quit Attempt
Communicate caring and concern.
Encourage the patient to talk about the quitting process.
Treating Tobacco Use and Dependence: 2008 Update” Clinical Guideline