Cancer, Cardiovascular and Pulmonary Pathophysiology Linked to Tobacco

1. Cancer, Cardiovascular and Pulmonary Pathophysiology Linked to Tobacco Carlos Roberto Jaén, MD, PhD, FAAFP Professor and Chairman Family and Community Medicine University of Texas Health Science Center at San Antonio

2. Overview • Health consequences of smoking on cancer, cardiovascular and pulmonary diseases • Smoking cessation strategies that work! • Leading edge areas of research in primary care clinical settings

3. Health Consequences of Smoking on Cancer, Cardiovascular and Respiratory Diseases The 2004 Surgeon’s General Report

7. Cancer • Most cells in the body continually divide and die off in a very controlled way. • Some chemicals can interfere with the cell division process, causing a cancer to develop. • Cancer tends to leave the original location and spread through the body; this is called “metastasis”. When the body cannot keep up with the growth of cancer, the patient dies.

8. Cancer • Cancer is the second leading cause of death in the United States. • In 2003 it is estimated that more than half a million would die from cancer, more than 1500 people a day. • The risk of dying from lung cancer is more than 22 times higher among men who smoke cigarettes, and about 12 times higher among women who smoke cigarettes compared with never smokers.

11. Cardiovascular Diseases • Heart disease and stroke are the first and third leading causes of death in the United States and are caused by smoking. • More than 61 million Americans suffer from some form of heart or blood vessel disease including high blood pressure, coronary heart disease, stoke and heart failure.

12. Cardiovascular Diseases • Nearly 2600 Americans die daily as a result of cardiovascular diseases or about one every 33 seconds. • Most cases of these diseases are caused by atherosclerosis, a hardening and narrowing of the arteries. • Damage to arteries and blood clots that block blood flow can cause heart attacks or strokes.

13. Cardiovascular Diseases • Cigarette smoke damages the cells lining the blood vessels and heart. • The damaged tissue swells, and makes it hard for blood vessels to get enough oxygen to cells and tissues. • Cigarette smoke increases the risk of dangerous blood clots both by redness and swelling and by causing blood platelets to clump together.

15. Pulmonary Diseases • Smokers have difficulty fighting infections well, these infections cause lung tissue injury that leads to chronic obstructive pulmonary disease (COPD), sometimes called emphysema and other pulmonary diseases. • People with COPD slowly start to die from lack of air.

16. Pulmonary Diseases • COPD is the fourth leading cause of death in the United States, accounting for about 100,000 deaths a year. • About 90% of all deaths from COPD are attributable to cigarette smoking. • Most sudden respiratory illnesses are caused by viruses and bacteria. Smokers have a weaken immune system that has difficulty clearing these infections from the lungs.

17. Pulmonary Diseases • Chronic lung diseases are long lasting and affect the airways and the tiny sacs where oxygen is absorbed into the lungs. • Injury begins when smoke causes lung tissue to become red and swollen. This releases unwanted oxygen molecules that damage the lung. It also causes release of enzymes that can eat delicate lung tissue.

21. So.. • Major cancers, cardiovascular and respiratory diseases are caused by tobacco use. • Is there experimental evidence that smoking cessation reduces mortality? • Are there effective treatments for smoking cessation?

22. The Lung Health Study • Randomized clinical trial of smokers with mild COPD treated with intense cessation intervention (12 two-hour sessions over 10 weeks) • Significant benefits of cessation at 14 ½ years of follow-up, even though only 22% quit in the intervention group vs. 5% in usual care group • First randomized trial to confirm prior epidemiological observations. Anthonisen, N. R. et. al. Ann Intern Med 2005;142:233-239

23. All-cause 14.5-year survival Anthonisen, N. R. et. al. Ann Intern Med 2005;142:233-239

24. Mortality rates at 14.5 years by cause and smoking status Anthonisen, N. R. et. al. Ann Intern Med 2005;142:233-239

25. Smoking Cessation Strategies that Work! Treating Tobacco Use and Dependence US PHS Clinical Practice Guideline, June 2000

26. Major Findings and Panel Recommendations 1. Tobacco dependence is a chronic condition that often requires repeated intervention. However, effective treatments exist that can produce long-term or even permanent abstinence.

27. Major Findings and Panel Recommendations 2.Because effective tobacco dependence treatments are available, every patient who uses tobacco should be offered one or more of these treatments.

28. Major Findings and Panel Recommendations 3. It is essential that clinicians and health care delivery systems institutionalize the consistent identification, documentation, and treatment of every tobacco user seen in a health care setting.

29. Major Findings and Panel Recommendations 4. Brief tobacco dependence treatment is effective, and every patient who uses tobacco should be offered at least brief treatment.

30. Major Findings and Panel Recommendations 5. There is a strong dose-response relation between the intensity of tobacco dependence counseling and its effectiveness. Treatments involving person-to-person contact (via individual, group, or proactive telephone counseling) are consistently effective, and their effectiveness increases with treatment intensity (e.g., minutes of contact).

31. Major Findings and Panel Recommendations 6. Three types of counseling and behavioral therapies were found to be especially effective and should be used with all patients attempting tobacco cessation: • Provision of practical counseling (problem-solving/skills training) • Provision of social support as part of treatment (intra-treatment social support) • Help in securing social support outside of treatment (extra-treatment social support)

32. Major Findings and Panel Recommendations 7. Numerous effective pharmacotherapies for smoking cessation now exist. Five first-line pharmacotherapies were identified that reliably increase long-term smoking abstinence rates: • Bupropion SR • Nicotine gum • Nicotine inhaler • Nicotine nasal spray • Nicotine patch

33. Major Findings and Panel Recommendations 7. Continued • Two second-line pharmacotherapies were identified as efficacious and may be considered by clinicians if first-line pharmacotherapies are not effective • Clonidine • Nortriptyline • Over-the-counter nicotine patches are effective relative to placebo, and their use should be encouraged

34. Major Findings and Panel Recommendations 8. Tobacco dependence treatments are both clinically effective and cost-effective relative to other medical and disease prevention interventions. As such, insurers and purchasers should ensure that: • All insurance plans include as a reimbursed benefit the counseling and pharmacotherapeutic treatments identified as effective in this Guideline • Clinicians are reimbursed for providing tobacco dependence treatment just as they are reimbursed for treating other chronic conditions

36. Clinical Interventions • The “5 A’s” for patients willing to make a quit attempt • The “5 R’s” for patients unwilling to make a quit attempt at this time • Relapse prevention for patients who have recently quit • Intensive interventions should be provided when possible • Health care administrators, insurers, and purchasers should institutionalize guideline findings

37. The “5 A’s” For Patients Willing to Quit • ASKabout tobacco use • ADVISEto quit • ASSESS willingness to make a quit attempt • ASSISTin quit attempt • ARRANGE for followup

38. Quit date: Set a stop date, preferably within 2 weeks Starting on the quit date, total abstinence is essential Review Past quit experiences Anticipate triggers or challenges in upcoming attempt Elements of a Counseling Intervention

39. Elements of a Counseling Intervention (cont’d) • Alcohol: • Since alcohol can cause relapse, the patient should consider limiting/abstaining from alcohol while quitting • Other smokers in the household: • Quitting is more difficult when there is another smoker in the household • Patients should encourage housemates to quit with them or not smoke in their presence

40. The “5 R’s” to Enhance Motivation for Patients Unwilling To Quit • RELEVANCE: Tailor advice and discussion to each patient • RISKS: Discuss risks of continued smoking • REWARDS: Discuss benefits of quitting • ROADBLOCKS: Identify barriers to quitting • REPETITION: Reinforce the motivational message at every visit

41. So.. • Smoking cessation reduces mortality and effective smoking cessation interventions exist. • Are smokers receiving these interventions in primary care practices? • What can we do to get more smokers to quit?

42. Why Primary Care Practice? • Most Americans see a primary care clinician • 60% of outpatient visits • Teachable moments • Relationships developed over time and multiple encounters

43. Competing Demands Theory • Many worthwhile services compete with each other for time on the agenda of primary care patient visits. • When primary care clinicians are not doing one activity under scrutiny (e.g. smoking cessation counseling), they may be doing something else that is more compelling. Jaén CR, Stange KC, Nutting PA. The competing demands of primary care: A model for the delivery of clinical preventive services. J Fam Pract. 1994; 38:166-171. Stange KC, Fedirko T, Zyzanski SJ, Jaén CR. How do family physicians prioritize delivery of multiple preventive services? J Fam Pract. 1994; 38:231-237.

44. Two Studies in Primary Care • The Direct Observation of Primary Care Study (DOPC) • Funded by the National Cancer Institute (NCI) • Prevention and Competing Demands • Funded by Agency for Healthcare Research and Quality (AHRQ) formerly known as AHCPR

45. Direct Observation of Primary Care (DOPC) • Methods • More than 4000 visits directly observed by research nurses. • Every 20 seconds up to 15 behaviors coded • 80 family practice offices in Northeastern Ohio • Patient exit surveys, chart reviews, practice assessments • Multimethod (qualitative and quantitative approaches) Stange KC, Zyzanski SJ, Jaén CR, et al. Illuminating the ‘black box’: A description of 4454 patient visits to 138 family physicians. J Fam Pract, 1998; 46:377-389.

46. Time for Tobacco Counseling • 55% of well care visits • 22% of illness visits • More common during visits for tobacco-related chronic illness vs. a visit for another chronic disease (32% vs. 17%) • Average duration of advice <1.5 minutes • Context of counseling not clear Jaén CR, Crabtree BF, Zyzanski SJ, Stange KC. Making time for tobacco counseling. J Fam Pract, 1998;46:425-428.

47. Prevention and Competing Demands Study • Multimethod comparative case study design in Nebraska • Direct observation and detailed descriptions of 1624 encounters by 50 clinicians in 18 family practices • In-depth interview of clinicians, office staff and community residents • Medical record review • Patient exit questionnaires CrabtreeBF. Miller WL. Stange KC. Understanding practice from the ground up. Journal of Family Practice. 50(10):881-7, 2001

48. Competing Demands and Tobacco Counseling • Hierarchy of taken & missed opportunities • Good (5As) counseling: 21% • Competing demands: 24% • Failure in a non-smoking related visit 27% • Failure in a smoking-related visit 25% • Failure in a health maintenance visit 2% • Guidelines to counsel every visit unrealistic • Systems & individual approaches are needed Jaén CR, McIlvain H, Pol L, Phillips RL, Flocke SA, Crabtree BF. Tailoring tobacco counseling to the competing demands in the clinical encounter. J Fam Pract, 2001; 50:859-863.

49. New Theoretical Framework • Complexity Science • “Primary care practices are complex adaptive systems facing the need to respond to internal and external uncertainty and surprise. For clinicians and practices to maximize their ability to proactively evolve as they respond to uncertainty and surprise, they need to understand that their practices are nonlinear systems and create the time and space for learning and reflection.” Crabtree BF. Primary Care Practices are Full of Surprises Health Care Management Review. 28(3):279-83, 2003 Miller WL. McDaniel RR Jr. Crabtree BF. Stange KC. Practice jazz: understanding variation in family practices using complexity science. Journal of Family Practice 50(10):872-8, 2001

50. Future Research • How can primary care practices be re-designed to improve delivery of smoking cessation services? • What can be done to improve integration of community and practice resources? • How can counseling for multiple health behaviors, e.g. tobacco and problem drinking be integrated into practices?