Transcript Risks of Tobacco/Tobacco Control

Risks of Tobacco/Tobacco Control
Edward Anselm, MD
Assistant Professor of Medicine
Icahn School of Medicine at Mount Sinai
Medical Director
Health Republic Insurance of New Jersey
Outline
• Describe the mechanisms by which tobacco causes a variety of
diseases
• Outline the factors relevant to epidemiology of tobacco use
• Describe the major tobacco control initiatives and their relative
success
• Discuss five end game strategies for tobacco control
• Describe the role of health professionals in smoking cessation
Why Tobacco?
Why do people smoke cigarettes?
Why do they start?
Why do they continue?
Per capita consumption of different forms of
tobacco in the United States, 1880–2011
What is in a cigarette?
What is in a cigarette?
• Tobacco leaves and stems
• Paper
• Additives
• Nicotine
• When burned this produces many additional chemicals known as
“tar”
What is in cigarette smoke?
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Arsenic: used in rat poison
Acetic Acid: hair dye and photo developer
Acetone: main ingredient in paint and fingernail polish remover
Ammonia: a typical household cleaner
Arylated Hyrdocarbons: cause mutations
Benzene: rubber cement
Cadmium: found in batteries
Carbon Monoxide: poisonous gas
Formaldehyde: used to embalm dead bodies
Hydrazine: used in jet and rocket fuels
Napthalenes: used in explosives, moth balls, and paint pigments
Phenol: used in disinfectants and plastics
Toluene: embalmer's glue
What are the effects of these chemicals?
• Irritation
• Oxidation
• Inflammation
• Increased cell turnover
• Inappropriate repair
• Increased chance of mutation
• Activation of oncogenes
• Decreased ability to repair DNA
• Impaired immunity
• Constriction of blood vessels
• Injury to endothelium/Increased atherogenesis
• Hyper-coaguable state
• Reduced oxygen
• Direct effects of Nicotine
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Multiply by intensity and repeated exposure over time
Respiratory System
• Active Smoking
• Acute respiratory illnesses, including pneumonia, in persons without underlying smoking-related chronic obstructive lung disease
• A premature onset of and an accelerated age-related decline in respiratory symptoms related to lung function in children and
adolescents, including coughing, phlegm, wheezing, and dyspnea
• Asthma-related symptoms (i.e., wheezing) in childhood and adolescence
• All major respiratory symptoms among adults, including coughing, phlegm, wheezing, and dyspnea
• Poor asthma control
• Chronic obstructive pulmonary disease morbidity and mortality
• Involuntary Exposure to Tobacco Smoke
• Lower respiratory illnesses in infants and children
• Middle ear disease in children, including acute and recurrent otitis media and chronic middle ear effusion
• Cough, phlegm, wheeze, and breathlessness among children of school age
• Ever having asthma among children of school age
• Onset of wheeze illnesses in early childhood
Cancer
• Adenocarcinoma of the lung
• Smokers and Passive smokers
• Head and Neck Cancers
• Hepatocellular Cancer
• Colorectal cancer
• Bladder cancers
• Worse outcomes with treatment
Cardiovascular Disease
• Coronary Artery Disease
• Health Attack
• Congestive Heart Failure
• Stroke
• Aneurysm
• Peripheral Vascular Disease
Reproductive Health
• Spontaneous Abortion
• Pre-term delivery
• Low birth weight
• Sudden Infant Death Syndrome
Cigarettes and Death
• Cigarette smoking causes about one of every five deaths in the United
States each year.1,6 Cigarette smoking is estimated to cause the
following:1
• More than 480,000 deaths annually (including deaths from secondhand
smoke)
• 278,544 deaths annually among men (including deaths from secondhand
smoke)
• 201,773 deaths annually among women (including deaths from
secondhand smoke)
• http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/to
bacco_related_mortality/
Smoking and Mental Illness
NSDUMH 2009 to 2011; Adults over 18
Overall prevalence of smoking
Prevalence of Any Mental Illness
Prevalence of smoking among people w AMI
21.4%
19.9%
36.1%
• AMI was highest among men, adults aged <45 years, and those living below the
poverty level;
• Smoking prevalence was lowest among college graduates.
• During 2009–2011, adults with AMI smoked 30.9% of all cigarettes smoked by
Adults.
MMWR / February 8, 2013 / Vol. 62 / No. 5
Smoking Prevalence and Income 1997 to 2012:
Overall smoking declined from 24.7% to 20.0%
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Below Poverty
Above Poverty
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Well above Poverty
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1997
2012
Nicotine
• Addiction
• Rats will press a bar to get nicotine
• Smokers maintain constant blood levels of nicotine
• Conditioned relaxation
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Situational triggers
Social
Acute stress
Chronic stress
• Habit
A Brief History of Tobacco Control I
• Early warnings 1948
• First Surgeon General’s Report 1964
• Fairness Doctrine 1967-1970
• Removal of Tobacco advertisement from television and radio 1970
• Tobacco Warning labels
• Role of the Tobacco Institute
• Marketing of light cigarettes
A Brief History of Tobacco Control
II
• Indoor pollution control 1987
• First Clinical Practice Guideline on smoking cessation 1996
• Master Settlement Agreement, 1998
• Media-based interventions
• Medications for smoking cessation; 1984 and after
• Telephonic quit lines
A Brief History of Tobacco Control
III
• Local and state interventions
• CDC documents best practices, 1999
• sets funding targets @$15-20 per capita, 2007
• FDA Regulation of nicotine, 2009
• PPACA, 2009 Coverage for smoking cessation
• Electronic Cigarettes
• Harm reduction
A Major Public Health Success
• Taxes
• Smoke-free environments
• De-normalization of smoking
• Paid advertising against smoking
• Graphic Warning Labels
• Evidence-based clinical interventions
Current Smoking Cessation Interventions
Five “A”s
Ask about smoking
Advise tobacco users to quit
Assess readiness to quit
Assist with a plan for quitting
Arrange follow-up
• Every patient quitting cigarettes
should be offered a medication
Two “A”s + R
Ask about smoking
Advise tobacco users to quit
Refer to cessation services
Five “R”s
Relevance
Risks
Rewards
Roadblocks
Repetition
Over 75% of smokers recall having been
advised to quit smoking in 2012
Discussing Cessation Strategies
Commercial
HMO PPO
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2012
2011
2010
2008
2007
2006
2005
2004
2003
47.9
47.6
45.0
49.7
48.0
43.2
38.9
36.8
36.0
37.3
40.1
39.0
43.3
44.2
42.6
35.1
Discussing Cessation Medications
Medicaid
HMO
41.1
40.3
38.5
40.8
39.2
36.7
33.9
32.7
32.3
Commercial
HMO PPO
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2012
2011
2010
2008
2007
2006
2005
2004
2003
52.9
53.1
52.4
54.4
50.9
43.9
39.4
37.8
37.6
NCQA 2013 State of Health Care Quality Report
44.6
47.9
47.2
50.9
49.6
43.8
36.7
Medicaid
HMO
45.8
44.3
42.7
40.6
38.7
35.1
31.8
31.3
31.5
End Game Strategies
Reducing nicotine yields
Gradual reduction of cigarette nicotine content to nonaddicting
levels through government action
Reducing product toxicity
Implementation of product regulatory standards to require
manufacture of tobacco products with very low toxicity
Gradual supply reduction
Phasing out tobacco use on a timetable by gradual reduction of
supply to zero or some minimal level
Prohibiting sales to future
Implementing a ban on sales for people born after a particular generation
date, so that smokefree cohorts are created that progressively
increase in coverage and size
Banning tobacco products
Ban on the production and sale of cigarettes
and/or cigarettes and additional tobacco products
Selling tobacco through a
To avoid the profit motive, transfer control of supply and sales
not-for-profit agency
to a not-for-profit agency that has the goal of reducing consumption