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Tobacco Related Disease and Cessation

Tobacco Related Disease and Cessation. Eric L. Johnson, M.D. Physician Consultant North Dakota Tobacco Quitline Department of Family and Community Medicine University of North Dakota School of Medicine and Health Sciences Grand Forks, ND. Objectives.

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Tobacco Related Disease and Cessation

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  1. Tobacco Related Disease and Cessation Eric L. Johnson, M.D. Physician Consultant North Dakota Tobacco Quitline Department of Family and Community Medicine University of North Dakota School of Medicine and Health Sciences Grand Forks, ND

  2. Objectives • Tobacco is a major contributor to death and disability in North Dakota • Tobacco Use is not just a Habit, it is a Nicotine Addiction • Effective Strategies exist to help people stop using Tobacco in outpatient and inpatient settings

  3. Tobacco Related Diseases

  4. State by State Smoking % Adults who smoke BRFSS 2006, CDC

  5. 500 400 300 No.(000s) 200 100 0 Annualsmokingdeaths Environ-mentaltobaccosmokedeaths AllWorldWar II Annualautoaccidents VietnamWar AIDS1983-1990 Annualmurders Annualheroin,morphine& cocainedeaths Tobacco Related Deaths-A Perspective Adapted from Dr. R. Hurt, Mayo Nicotine Dependence Center Used By Permission

  6. 13.2-14.5 years of life lost due to smoking

  7. Smoking Causes Death Smoking causes approximately • 90% of all lung cancerdeaths in men • 80% of all lung cancerdeaths in women • 90% of deaths from chronic obstructive lung disease (COPD) CDC

  8. Smoking Causes Death Compared with nonsmokers smoking increases risk of— • Coronary heart disease by 2 to 4 times • Stroke by 2 to 4 times • Men developing lung cancer by 23 times • Women developing lung cancer by 13 times • Dying from chronic obstructive lung diseases (COPD) by 12 to 13 times CDC

  9. Tobacco Use in North Dakota • ~116,000 ND adults and ~8,000* HS students smoke cigarettes • ~20,000 ND adults and ~3,800^ HS students use spit tobacco -HS students: *26% in 2003, 27% in 2005, 22% in 2007 ^10% in 2003, 12.7% in 2005, 10.2% in 2007 (BRFSS 2008) (YRBS 2005,2007)

  10. North Dakota Department of Health Division of Tobacco Prevention and Control

  11. North Dakota Department of Health Division of Tobacco Prevention and Control

  12. Tobacco Use in North Dakota • Native American population: 49.3% adults use tobacco (highest smoking rate of any ethnic group in U.S.) • Smoking in pregnancy higher in North Dakota than national average: 18% vs. 12% • WIC Clinic population survey: 45% smoked prior to pregnancy vs. 16% non-WIC

  13. Tobacco Use in North Dakota -Between 2001 and 2008, Adult smoking rates in North Dakota dropped from 23.2% to 18.1%, similar to national trends -Healthy People 2010 Goal (Now): 12% or less -52% report cessation attempts annually Behavioral Risk Factor Surveillance System (BFRSS)

  14. Tobacco’s Health Cost inNorth Dakota • Smoking-attributable direct medical expenditures: $250,000,000 • Smoking-attributable productivity costs: $192,000,000 • Medicaid expenditures for smoking-related illnesses and diseases: $47,000,000 Annual Costs! CDC. Smoking-Attributable Mortality, Morbidity and Economic Costs (SAMMEC) report, 2008. CDC Data Highlights, 2006.

  15. North Dakota spends $691 per capita on direct medical expenditures andlost productivity due to smoking

  16. Tobacco Use in North Dakota • Heart Disease and Cancer are the leading causes of death in North Dakota • Tobacco use is the leading preventable cause of death

  17. Secondhand Smoke Deaths United States • Lung cancer – 3,000 deaths annually • Ischemic heart disease – 35,000 deaths annually North Dakota • 80-140 deaths annually

  18. Tobacco and Cardiovascular Disease(Heart Disease and Stroke)

  19. Coronary Heart Disease • Leading cause of death in the USA • Smoking attributable mortality 30% • Most of decline in incidence is because of  smoking rate • ~100,000 CVD deaths due to smoking and >35% occur before age 65 • 2-6X  risk of sudden death in smokers • Over 1.6 million coronary procedures/year American Heart Association Report of the U.S. Surgeon General 2004

  20. Cerebrovascular Disease-Stroke • 600,000 cases/year in U.S. • 30 % fatality rate at one year • Similar risk factors as Coronary Heart Disease

  21. Smoking and Cardiovascular Disease • Quitting smoking will lower risk substantially in about 5 years • Smokers with established CVD lower risk of subsequent events by quitting smoking

  22. Tobacco and Cancer

  23. U.S. 1997-2001 MMWRJuly 1, 2005 / 54(25);625-628 US Surgeon Generals Report 2004

  24. U.S. 1997-2001 MMWRJuly 1, 2005 / 54(25);625-628 US Surgeon Generals Report 2004

  25. COPD and Smoking • 4th leading cause of death • Accounts for > 100,000 deaths/yr • Symptomatic improvement and lung function preservation with tobacco cessation Report of the U.S. Surgeon General 2004 American Lung Association

  26. Tobacco Cessation Improves Surgical Outcomes • Cardiovascular complications • Respiratory complications • Wound-related complications • Many elective procedures require tobacco cessation

  27. Special Populations

  28. Special Populations • Pregnancy: NRT is Category D risk vs benefit • Mental Illness: NRT or nicotine withdrawal can affect levels of some psych meds. Varenicline? Depends on status • Chemical Dependency: Higher death rate from tobacco (~50%) than alcohol (~33%)

  29. Smoking and Diabetes • Strong Association between smoking history and development of Type 2 Diabetes • Now thought to be an independent risk factor, like obesity • Several large studies to date with more recent interest • Already a high risk CVD population • Glucose control may be worse

  30. Tobacco Cessation

  31. Nicotine is addictive…and this is precisely why it is there • The cigarette is a highly engineered nicotine delivery device • Chemicals like ammonia are added to release more nicotine (~freebasing) • Nicotine is there on purpose, for a purpose • Nicotine is not a carcinogen (patients may not know this)

  32. Nicotine Withdrawal • Symptoms -anger/irritability -depression/anxiety -insomnia -increased dream activity • Peak in 1st week, last 2-4 weeks • ~50% experience significant withdrawal symptoms • Most patients underestimate withdrawal symptoms Hughes Nic Tob Res 2007 Madden Addiction 1997 Stages J Clin Psych 1996

  33. 1st Line Pharmacotherapy(Medications)For Tobacco Cessation

  34. Pharmacotherapy • Nicotine replacement therapy (NRT) • Gum • Patch • Spray • Inhaler • Lozenge • Bupropion (Zyban, Wellbutrin) • Varenicline (Chantix) • Other medications in development

  35. Nicotine replacement therapy • Replace the nicotine supplied by cigarettes • Conversion: Each cigarette provides 1 mg of nicotine • Combination therapy • Most people underdose NRT, or don’t take it long enough

  36. Nicotine Replacement Therapy (NRT) • 1mg for each cigarette smoked • 10 cigs=10mg • 20 cigs=20mg • 40 cigs=40mg • Note: may exceed label recommendations

  37. Bupropion • Inhibits reuptake of dopamine & norepinephrine • Exact mechanism of action in smoking cessation is not clear • Initially developed as an antidepressant • Promotes smoking cessation even in the absence of depression

  38. Varenicline(Chantix) • A partial nicotine receptor antagonist • Binds to the nicotine receptors in the brain • “Feeds the need” for nicotine at the CNS level • Essentially a “form of NRT”

  39. Varenicline • Most common side effects - nausea (16-30%) - insomnia (18-19%) - abnormal dreams (9-13%) • Weight-neutral • New FDA warning-monitor for changes in mood/mental status/behavior

  40. Medication Selection • NRT good in many settings, combine with Buproprion in some • Varenicline avoid in unstable psych. Not generally used along with NRT • Others, see full package data

  41. NRT Screening ND QL NRT screening • Unstable or recently treated heart problem • Arrhythmia • Uncontrolled BP • All other meds and OTC’s • Stomach ulcer • Tape allergy • Smokeless tobacco

  42. NRT Relative Contraindications • Vasospastic disease • Renal or Liver disease • Lactating or Pregnant • Pheochromocytoma • Uncontrolled hyperthyroidism • Diabetes (esp poorly controlled/longstanding-silent CAD?)

  43. Medications typically will give better results when combined with counseling

  44. Effective Strategies Exist to Assist in Quitting Tobacco

  45. Approaches to Tobacco Cessation • Personalize • “Smoking is bad”-worthless statement, everybody knows smoking is bad • Tie to a condition, i.e., heart disease, chronic sinus infections, lung disease, etc (relevant to patient at that time) • Economic- speaks to a lot of patients

  46. Inpatient Tobacco Cessation • Smoke free facility. No exceptions. • Institute NRT in appropriate patients • Varenicline or Burproprion can be started in appropriate patients • Use of meds in ICU, CCU, SICU controversial • Inpatient tobacco cessation more effective if followup plan i.e., Quitline, Quitnet • Inpatients are welcome to access QL/QN

  47. Telephone Quitlines and Online Services

  48. Tobacco Quitlines“Telephone quitline counseling is effective with diverse populations and has broad reach. Therefore, clinicians and healthcare delivery systems should both ensure patient access to quitlines and promote quitline use”Treating Tobacco Use and DependenceUS Department of Health and Human ServicesPublic Health Service2008 Update

  49. Quitlines and Quitnet • North Dakota and Minnesota have telephonic and web based services • Altru has typically been a good supporter of telephonic services in North Dakota

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