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Tobacco Cessation In Special Populations

Tobacco Cessation In Special Populations. Eric L. Johnson M.D. Assistant Professor Department of Family and Community Medicine University of North Dakota School of Medicine and Health Sciences. Objectives. Identify the scope of tobacco’s impact in North Dakota

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Tobacco Cessation In Special Populations

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  1. Tobacco Cessation In Special Populations Eric L. Johnson M.D. Assistant Professor Department of Family and Community Medicine University of North Dakota School of Medicine and Health Sciences

  2. Objectives • Identify the scope of tobacco’s impact in North Dakota • Discuss common disease states associated with tobacco use • Discuss and apply tobacco cessation needs for special populations

  3. Special Populations • Diabetes- already at high risk for cardiovascular disease, smoking as a cause/exacerbation of diabetes • Pregnancy- poorer pregnancy outcomes • Mental Illness/Chemical Dependency- - high utilization, difficult to treat • Adolescents- Difficult to engage, limited data on medications • Native Americans- High utilization, barriers

  4. Overview of Tobacco

  5. 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

  6. 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

  7. Secondhand Smoke Deaths United States • Lung cancer – 4,000 deaths annually • Ischemic heart disease – 45,000 deaths annually North Dakota • 80-140 deaths annually CDC

  8. State by State Smoking % Adults who smoke BRFSS 2009, CDC

  9. Tobacco Use in North Dakota • ~100,000 ND adults and ~8,000* HS students smoke cigarettes • ~20,000 ND adults and ~3,800^ HS students use spit tobacco (BRFSS 2008) (YRBS 2005,2007,2009)

  10. Tobacco Use in North Dakota • Between 2001 and 2009, Adult smoking rates in North Dakota dropped from 23.2% to 18.6% • Highest West Virginia 25.6% • Lowest Utah 9.8% • About half of smokers report cessation attempts annually Behavioral Risk Factor Surveillance System (BFRSS) MMWR

  11. 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.

  12. General Issues in Smoking Cessation • Triggers • Mood changes • Withdrawal symptoms (most smokers underestimate) • Weight gain • Lack of support • Exposure to other smokers

  13. Tobacco Cessation Counseling • Brief counseling (i.e., 5A’s) • Classes • Quitline/Quitnet/Quitplan • 3rd party payer programs

  14. Pharmacotherapy • Nicotine replacement therapy (NRT) • Bupropion (Zyban, Wellbutrin) • Varenicline (Chantix) • First-line therapies USPHS Guidelines 2008

  15. Smoking and Diabetes

  16. 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

  17. Does smoking cause diabetes? • Growing evidence points to smoking as an independent risk factor for developing diabetes • Large prospective studies with multivariate adjustments still do point to a causal link

  18. Smoking and Diabetes Risk • Women’s Health Study RR 1.42 AJPH 1993 • Men’s Health Professionals Study RR 1.94 BMJ 1995 • Osaka Study RR 1.47- 1.73 Diabetes Med 1999 • Physician’s Health Study RR 2.1 Am J Med 2000 • Cancer Prevention Study 1 RR 1.45-2.1 I Jour Epi 2001

  19. Smoking and Diabetes • The Translating Research Into Action for Diabetes (TRIAD) Study • Smoking increased relative risk of all cause mortality of 1.44 McEwon, et al Diabetes Care 2007

  20. Passive (Second Hand)Smoking and Diabetes • The High-Risk and Population Strategy for Occupational Health Promotion (HIPOP-OHP) study • Relative risk of type 2 Diabetes 1.81 with secondhand exposure • Relative risk of type 2 Diabetes 1.99 for active smokers Hayashino, et al Diabetes Care 2008

  21. Effects of smoking on diabetes • Increased random and fasting glucose • Increased HbA1C • Increased insulin resistance • All these despite a lower average BMI • Recent study showed 9.8% of youth with diabetes smoke Reynolds, et al ADA meeting abstract 2008 Haire-Joshu, et al Diabetes Care 1999

  22. Medications for Smoking Cessation in Diabetes • NRT • Buproprion • Varenicline (Chantix) • All can be used in diabetes, avoidance of weight gain important

  23. Tobacco and Diabetes • Smoking is a cause of type 2 diabetes • Smoking worsens diabetes control • Smoking increases risk of CVD and other complications • Smoking cessation is critical in diabetes • Consider appropriate medications • Refer to ND Quitline/Quitnet, MN Quitplan, other local resources

  24. Tobacco and Pregnancy

  25. Tobacco Cessation in Pregnancy • Benefits in pregnancy and long term health (interventions in younger women) • Reduce Cardiovascular Complications • Reduce Lung Disease • Reduce Cancer • Reduce Type 2 Diabetes • Economic benefit for individual and society

  26. Smoking in Pregnancy • Smoking in pregnancy higher in North Dakota than national average: 18% vs. 11% • Smokers tend to be from lower socioeconomic and educational classes • WIC smoking population as high as 40%+ in North Dakota North Dakota Department of Health

  27. Smoking in Pregnancy • ~75% of pregnant smokers desire quitting • ~25-30% actually quit during pregnancy • ~50% resume after pregnancy • Smoking Cessation is most successful prior to pregnancy Ruggiero L, et al Addict Behav. 2000 Mar-Apr;25(2):239-51 Ebert LM Fahey K Women Birth. 2007 Dec;20(4):161-8 Tong VT, et al Am J Prev Med. 2008 Oct;35(4):327-33.

  28. Complications of Smoking in Pregnancy • Fourfold increase in small for gestational age; Increased prematurity • Twice the rate of spontaneous abortions • Increased risk of abruptio placentae, placenta previa, premature and prolonged rupture of membranes Russell, T, et al Nicotine & Tobacco Research, Vol6, Supp 2. Apr. 2004 Gabbe: Obstetrics 4th ed 2002 George L, et al Epidemiology. 2006 Sep;17(5):500-5 Faiz AS, Ananth CV.J Matern Fetal Neonatal Med. 2003

  29. Complications of Smoking in Pregnancy • Intrauterine growth restriction • Stillbirth • Ectopic pregnancy • Infertility • Poor wound healing/surgical outcomes Russell, T, et al Nicotine & Tobacco Research, Vol6, Supp 2. Apr. 2004 Gabbe: Obstetrics 4th ed 2002 Högberg L, Cnattingius G. BJOG. 2007 Jun;114(6):699-704.

  30. Fetal/Child Effects of Maternal Smoking in Pregnancy • Sudden infant death syndrome (SIDS) and increased respiratory illnesses in children • Possible Association with maternal smoking and ADHD/Behavioral Disorders • Congenital Anomalies (i.e., cleft lip/palate, cardiac) Linnett KM, et al Pediatrics 2005; 116: 462-467 Malik S, et al Pediatrics 2008 Apr;121(4):e810-6 Shi M, et al Am J Hum Genet. 2007 Jan;80(1):76-90

  31. Smoking Cessation Interventions in Pregnancy • Brief Office Counseling • Smoking Cessation Class (i.e., Public Health) • Third Party Payer programs • Quitlines • Online programs (i.e., Quitnet) • Pharmacologic

  32. Pharmacotherapy for Pregnant Smokers • NRT- Category D. Secreted in breast milk. Crosses placenta • Buproprion (Wellbutrin, Zyban)- Category B. Metabolites in breast milk. Risk of seizure (low). Increase spontaneous abortion 1st trimester? • Varenicline (Chantix)- No data (yet) Oncken CA, Kranzler HR Nic Tob Res Nov 2009

  33. Pharmacotherapy for Pregnant Smokers • USPHS 2008 more limited recommendations vs USPHS 2000 • ACOG 2005: NRT for heavy smokers if other nonpharmacologic interventions fail

  34. Pharmacotherapy for Pregnant Smokers • NRT use must be risk vs benefit -heavy smoker, relapsers, other risk ? (i.e. CVD risk factors) -if NRT used, intermittent (gum, lozenge) -higher birth weight? • Buproprion? 1 study shows benefit * • Varenciline- not recommended presently *Chan B et al J Add Dis (24) 19-23 2005

  35. Pharmacotherapy for Pregnant Smokers • Smoking, Nicotine, and Pregnancy Trial • Currently underway (UK study) • Projected publication is 2013

  36. Smoking Cessation Interventions in Pregnancy • Pregnancy affords a great opportunity • Multiple short term followup clinic visits • Phone calls/e-mail/quitline/quitnet • ASK every time • Options every time • North Dakota data encouraging

  37. Tobacco Use and Mental Illness

  38. Tobacco Use and Mental Illness • Tobacco use in patients with a psychiatric diagnosis ~41% • Tobacco use patients without a psychiatric diagnosis ~20% Lasser, et al JAMA 2000

  39. Tobacco Use and Mental Illness • Lifetime quit rates for ever smokers with a psychiatric diagnosis 16%-26% • Lifetime quit rates for ever smokers without psychiatric diagnosis ~42% • Persons with mental illness consume 30-50% of all tobacco sold in the U.S. Lasser, et al JAMA 2000 Fagerstrom and AubinCurr Med Res Op 2009

  40. Mental Illness Smoking Rates • Schizophrenia 80%+ • Depression 40-60% • Bipolar Disorder 40-70% • Anxiety Disorders 20-50% • PTSD 50-65%

  41. Factors Influencing Smokingin Mental Illness • Nicotine may improve symptoms of schizophrenia • Nicotine may improve symptoms of depression • Withdrawal from nicotine may exacerbate symptoms in mental illness Dalak, et al Am J Psych 1999 Malpass and Higgs Psychopharm 2007

  42. Smoking Cessation Interventions in Mental Illness • Brief Office Counseling (5 A’s) • Smoking Cessation Class (i.e., Public Health, Lung Association) • Third Party Payer programs • Quitlines • Online programs (i.e., Quitnet) • Pharmacologic

  43. Considerations/Complications of Smoking Cessation Therapy In Mental Illness • Tobacco can lower serum levels of some psychiatric drugs • Induction of CYPIA2 • Therefore, cessation may alter serum levels of some psychiatric drugs • Monitoring for side effects, change in status, etc important Fagerstrom and Aubin Curr Med Res Op 2009

  44. Management of Emergent Psychiatric Symptoms in Tobacco Cessation • Monitor for symptoms • NRT +/- buproprion if appropriate (depression) • Adjustment of other psych medications • Cognitive behavioral therapy (CBT) • Motivational Interviewing • Varenicline? Can exacerbate some symptoms

  45. Medications for Tobacco Cessation in Mental Illness • NRT: Be aware of interactions with psych meds, but more data • Buproprion: May be useful to co-manage depression, depends on other meds used • Varenicline: Not a lot of data, but can exacerbate some symptoms Fagerstrom and AubinCurr Med Res Op 2009

  46. Tobacco Use and Chemical Dependency

  47. Tobacco and Chemical Dependency • We treat all other aspects of chemical dependency simultaneously • Nicotine (tobacco) is an addictive drug with adverse health effects • Treat chemical dependency, need to lower risk of dying prematurely from a tobacco related disease in recovery

  48. Nicotine Dependence in the Chemically Dependent Population • Smoking rate in the general population ~20% • Smoking rate in the chemically dependent population ~80+% • Smoking is more deadly to chemically dependent population: 4 times the death rate of non-smokers 51% of deaths from tobacco 33% of deaths from drugs or alcohol CDC 2005; Walsh, etal Drug & Alcohol Review (24) 2005; Hurt, et al Alcoholism: Clin & Exp Res (18) 1994

  49. Benefits of Smoking Cessation in CD Treatment • Smoking tobacco and drinking alcohol are strongly inter-related Gulliver, et al J Stud Alc 2000 • Urges to smoke = Urges to drink Cooney, et al Psych Addict Beh 2007 • Increased smoking = Increased drinking Barrett, et al Drug Alc Dep 2006 • Other concomitant addictions are treated

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