Tobacco and Your Patient

3. Tobacco and Your Patient

12. Tobacco Use and Your Patient Donald Shell, M.D., MA Interim Director Center for Health Promotion Education And Tobacco Use Prevention Department of Health and Mental Hygiene

13. Tobacco Use and Your Patient • Multiple Surgeon General’s reports (2004, 2006, 2010) have established long list of health consequences and diseases caused by tobacco use and exposure to tobacco smoke • This presentation will: • Review the biological and behavioral mechanisms that may underlie the pathogenicity of tobacco smoke • Review the health consequences caused by exposure to tobacco smoke • Not review evidence on the mechanism of how smokeless tobacco causes disease (future webinar)

14. Quitting Will Save Your Patients’ Lives Tobacco Use • Remains the leading preventable cause of death and disease in the United States. • Recent studies show that brief advice from a clinician about smoking cessation yielded a 66% increase in successful quit rates. • Tell your patient that quitting smoking is the most important step they can take to improve their health. They will listen to you.

15. Tobacco Use - Single Largest Preventable Cause of Death and Disease in the US • Health consequences of tobacco use • Heart disease • Multiple types of cancer • Pulmonary disease • Adverse reproductive effect • Chronic health conditions • 443,000 Americans die each year • Smoking costs US $193 billion in medical expenses & lost productivity

16. Health Consequences Causally Linked to Smoking Chronic Diseases Stroke Blindness, cataracts Periodontitis Aortic aneurysm Coronary heart disease Pneumonia Atherosclerotic peripheral vascular disease Chronic obstructive pulmonary disease, asthma, and other respiratory effects Hip fractures Reproductive effects in women (including reduced fertility)

17. Health Consequences Causally Linked to Smoking Cancers Oropharynx Larynx Esophagus Trachea, bronchus, and lung Acute myeloid leukemia Stomach, Pancreas, Kidney and ureter Cervix, Bladder

18. Health Consequences Causally Linked to Exposure to Secondhand Smoke Children Middle ear disease Respiratory symptoms, impaired lung function Lower respiratory illness Sudden infant death syndrome Adults Nasal irritation Lung cancer Coronary heart disease Reproductive effects in women: low birth weight

19. TobaccoMechanisms of Disease Production • There is no risk free level of exposure to tobacco smoke • Inhalation of tobacco smokes complex chemical mixture of combustion compounds causes adverse health outcomes through: • DNA damage • Inflammation • Oxidative stress • Risk and severity directly related to duration and level of exposure

20. TobaccoMechanisms of Disease Production • Insufficient evidence that product modification strategies to lower toxicant emissions in tobacco: • Reduce risk for major adverse health outcomes • Sustained use and long term exposure to tobacco smoke: • Mediated by diverse actions of nicotine at multiple nicotinic receptors in the brain • Powerfully addictive

21. Tobacco and CancerMechanisms of Disease Production • Carcinogen exposure and resultant DNA damage in smokers direct result of numerous cytogenetic changes present in lung cancer • Mutations in TP53 and KRAS in lung cancer • Promoter methylation of key tumor suppressor genes such as P16 in smoking-caused cancers • Nicotine and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone activate signal transduction • Receptor mediated events • Allow survival of damaged epithelial cells that would normally die

22. Tobacco and CancerMechanisms of Disease Production • Metabolic activation of cigarette smoke carcinogens by cytochrome P-450 enzymes has a direct effect on the formation of DNA adducts • Consistent evidence for an inherited susceptibility of lung cancer • Some less common genotypes are unrelated to familial clustering of smoking behaviors • Smoking cessation is the only proven strategy to reduce the pathogenic process leading to cancer

23. Tobacco and CardiovascularMechanisms of Disease Production • Nonlinear dose response between tobacco smoke exposure and cardiovascular risk • Sharp increase at low levels of exposure • Infrequent smoking or 2nd hand smoke exposure • Cigarette smoking: • Leads to coronary and peripheral artery endothelial dysfunction resulting from • Oxidizing chemicals and nicotine in tobacco smoke

24. Low levels of exposure (including 2nd hand smoke) lead to a rapid and sharp increase in endothelial dysfunction and inflammation Implicated in acute cardiovascular events and thrombosis

25. Tobacco and CardiovascularMechanisms of Disease Production • Cigarette smoking produces: • Chronic inflammation • Contributes to atherogenic disease processes • Elevates levels of biomarkers of inflammation • Predictors of cardiovascular events • Atherogenic lipid profile • Primarily due to an increase in triglycerides and a decrease in high-density lipoprotein cholesterol • Insulin resistance and chronic inflammation • Accelerates macrovascular and microvascular complications including nephropathy

26. Tobacco and CardiovascularMechanisms of Disease Production • Smoking Reduction: • Smoking fewer cigarettes per day does not reduce the risk of cardiovascular disease • Smoking cessation: • Reduces the risk of cardiovascular morbidity and mortality for smokers with or without coronary heart disease • Facilitated by the use of nicotine or other medications in patients with known cardiovascular disease • Produces far less cardiovascular risk that the risk of continued smoking

27. Tobacco and PulmonaryMechanisms of Disease Production • COPD • Oxidative stress from tobacco smoke exposure has a role in the pathogenic process • Inherited genetic variations in genes such as SER-PINA3 is involved in pathogenesis • Protease-antiprotease imbalance has a role in the pathogenesis of emphysema • Smoking cessation is the only proven strategy for reducing the pathogenic process leading to COPD

28. Tobacco Reproductive and Developmental Mechanisms of Disease Production • Consistent Evidence: • Smoking in men linked to chromosome changes or DNA damage in sperm (germ cells) • Affecting male fertility, pregnancy viability, offspring anomalies • Association of periconceptional smoking to cleft lip with or without cleft palate • Genetic polymorphisms (i.e. transforming growth factor-alpha) modify risk of oral clefting • Smoking in women: • Increased FSH and decreased estrogen and progesterone levels (nicotine endocrine effects) • Diminished oviductal functioning (impaired fertility)

29. Tobacco Reproductive and Developmental Mechanisms of Disease Production • Consistent Evidence That Maternal Smoking: • Transiently increases maternal heart rate, BP (diastolic) by norepinephrine and epinephrine release • Interferes with physiological transformation of spiral arteries and thickening of the villous membrane in the forming placenta • Fetal loss, preterm delivery, low birth weight

30. Tobacco Reproductive and Developmental Mechanisms of Disease Production • Consistent Evidence That Maternal Smoking: • Histopathologic changes in the fetus • Primarily in the brain and lung • Adverse impact on a variety of reproductive endpoints from polycystic aromatic hydrocarbons • Immunosuppressive (dysregulated inflammatory response) • Lead to miscarriage and preterm delivery

31. Tobacco Reproductive and Developmental Mechanisms of Disease Production • Consistent Evidence Links: • Carbon monoxide to birth weight and neurological (cognitive and neurobehavioral endpoint) deficits • Prenatal smoke exposure and genetic variation in metabolizing enzymes such as GSTT1 with increased risk of adverse pregnancy outcomes • lowered birth weight and reduced gestation

32. SummaryTobacco Mechanisms of Disease • Smoking cessation: • The only proven strategy to reduce the pathogenic process leading to cancer • reduces the risk of cardiovascular morbidity and mortality for smokers with or without coronary heart disease • the only proven strategy for reducing the pathogenic process leading to COPD • Use of nicotine or other medications in patients with known cardiovascular disease produces far less cardiovascular risk than continued smoking

33. Tobacco Use and Your Patient Donald Shell, M.D., MA Interim Director Center for Health Promotion, Education And Tobacco Use Prevention Department of Health and Mental Hygiene 300 W. Preston Street, Suite 410 Baltimore, MD 21201 (410) 767-1365 dshell@dhmh.state.md.us

34. Brief Intervention and the 5 A’s: Helping Patients Quit Tobacco Dr. Carlo DiClementeDirector, MDQuit Resource Center Sponsored by Maryland Department of Health and Mental Hygiene and University of Maryland Baltimore County

36. Brief Intervention and the 5 A’s: Helping Patients Quit Tobacco Dr. Carlo DiClementeDirector, MDQuit Resource Center Sponsored by Maryland Department of Health and Mental Hygiene and University of Maryland Baltimore County

37. What is ? Resource center for tobacco use cessation and prevention for the State of Maryland. Funded by the Maryland Department of Health and Mental Hygiene (DHMH). Located on the campus of the University of Maryland, Baltimore County (UMBC). Dedicated to assisting providers and programs in reducing tobacco use among citizens across the state utilizing best practices strategies.

38. The Big Picture – 2007 There are 90.7 million ever smokers in the U.S. Over 52% of these are now former smokers Prevalence has dropped from 42% in 1965 to 19.8% in 2007 43.4 million people are still smoking the U.S. (19.8% of adults) 77.8 % of smokers smoke every day 38.4% stopped smoking for one day in the past year because they were trying to quit

39. The Smoker’s Journey Social pressure Policy Products & Services Price Social Support Smoking In Network Promotion Long Term Success Tobacco Advertising Satisfied Dependent or Casual Smoker Choosing A Method NRT, TX, Cold Turkey, Quitline Dissatisfied but ambivalent Decided to Make a Quit Attempt Quit Attempt Short Term Success Personal Concerns Special Events Relapse And Recycling Psychiatric Conditions And Other Life Problems Quitting History Beliefs & Myths

40. Stages of Change for Smoking Cessation: 2008 MATS • Precontemplation: Current smokers who are not planning on quitting smoking in the next 6 months • Contemplation: Current smokers who are planning on quitting smoking in the next 6 months but have not made a quit attempt in the past year • Preparation: Current smokers who are definitely planning to quit within next 30 days and have made a quit attempt in the past year • Action: Individuals who are not currently smoking and have stopped smoking within the past 6 months • Maintenance: Individuals who are not currently smoking and have stopped smoking for longer than 6 months but less than 5 years DiClemente, 2003

41. Changes with 2008 Note: includes ever-smokers (100+ cigarettes in lifetime) who are current smokers or former smokers (including those who have quit for 5+ years)

44. Physician Brief Intervention is a Best Practice “All physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates.” “Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates.” “Every tobacco user should be offered at least a minimal intervention, whether or not he or she is referred to intensive intervention.” Recommendations with Strength of Evidence = A Fiore et al. (2008). Treating Tobacco Use and Dependence: Clinical Practice Guideline 2008 Update.

45. Doctors Helping Smokers:Myths and Realities Kottke et al., 1994 (NCI)

46. Brief Intervention for Tobacco: Goals Focus on supporting quit attempts based on the extent to which a patient is: Ready Willing Able Provide the patientwith feedback and assistance that meets his/her current needs. x Readiness Willingness Abilities

47. Treating Tobacco Using the 5 A’s Current User No Current Use Ready to Quit Yes No

48. The “5 A’s” For Brief Intervention

49. 1. ASK: about tobacco use every time • Implement a standard system to ensure that for every patient at every visit, tobacco use is queried and documented. • Some settings expand the vital signs to include tobacco use, viewing it as equally important as taking a patient’s blood pressure or asking about current symptoms. • Ask patients: • Have you smoked a cigarette, even a puff, in the past 30 days? • On average, how many cigarettes do you smoke per day? • How long have you been smoking at that rate? • A person’s smoking status and readiness to make a quit attempt can change across visits.

50. 2. ADVISE: Urge ALL tobacco users to quit Provide Clear, Concise, Strong and Personalized Advice: As your physician, I recommend that you quit using tobacco. The clinic staff and I will help you. As your smoking has increased, your breathing has worsened. Right now, quitting smoking is the best thing you can do for your health. Expect ambivalence. Be willing to listen non-judgmentally to patient concerns. Ask: What do you make of this advice?