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Why we don't have always success to treat the smoker

Why we don't have always success to treat the smoker. Fl.Mihaltan * * Institutul de Pneumologie “ M.Nasta ” - Bucuresti mihaltan@starnets.ro. Contents. Introduction Barriers which depend on doctors Barriers generated by patients Barriers which depend on system

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Why we don't have always success to treat the smoker

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  1. Why we don't have always success to treat the smoker Fl.Mihaltan* *Institutul de Pneumologie“M.Nasta”- Bucuresti mihaltan@starnets.ro

  2. Contents • Introduction • Barrierswhich depend on doctors • Barriersgenerated by patients • Barrierswhich depend on system • Barriers which depend on tobacco industry • Conclusions

  3. Introduction

  4. Estimated curve - cumulative deaths from tobacco 520 500 400 300 220 Cumulative deaths from tobacco (millions) 200 70 100 0 1950 1975 2000 2025 2050 Year 5 5 The World Bank 1999 Curbing the Epidemic : Governments and the Economics of Tobacco Control. World Bank Publications, Washington DC

  5. Estimated curve - cumulative deaths from tobacco 520 500 500 Trend If smoking uptake halves by 2020 400 300 220 Cumulative deaths from tobacco (millions) 200 70 100 0 1950 1975 2000 2025 2050 Anul 6 6 The World Bank 1999 Curbing the Epidemic : Governments and the Economics of Tobacco Control. World Bank Publications, Washington DC

  6. Estimated curve - cumulative deaths from tobacco 520 500 500 Trend If smoking uptake halves by 2020 400 340 300 220 If adult smoking halves by 2020 Cumulative deaths from tobacco (millions) 200 190 70 100 0 1950 1975 2000 2025 2050 Anul 7 7 The World Bank 1999 Curbing the Epidemic : Governments and the Economics of Tobacco Control. World Bank Publications, Washington DC

  7. Smoking cessation - years gained of life expectancy • 3 years at age 60 • 6 years at age 50 • 9 years at age 40 • 10 years at age 30 BMJ 2004;328:1519

  8. Barrierswhich depend on doctors

  9. What are the barriers? Patient negative reaction Lack of efficacy and desire Medical deficiencies? Time consumer Expectations

  10. Medical deficiencies Vogt et al. Addiction 2005;100:1423-1431

  11. Problems which depend on medical staff Health professionals - Not interested in the routine on smoking behaviour The little "training" in advising smoker Not convinced of their ability to help smokers In some countries, many health professionals are smokers

  12. Survey of psychiatrists, family practitioners, ob/gyns, and general internists (~3000 returned surveys)1 7% 13% 17% 24% 25% 26% 29% 31% 37% 63% 68% 84% What is the behavior of american physician Percent of Physicians Who “Usually” … 86% Advise patients to stop smoking Ask about smoking status Discuss pharmacotherapies Assess patient willingness to quit Discuss counseling options Recommend NRT Discuss enlisting support Monitor patient progress Prescribe other medications Provide brochures/ self-help materials Arrange follow-up visits Refer patients to others for treatment Refer patients to a quitline 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% • Adapted from: American Legacy Foundation. Physician Behavior and Practice Patterns Related to Smoking.AAMC; 2007. Available at: http://www.aamc.org/workforce/smoking-cessation-full.pdf

  13. Advise smoker Time consuming 42% of doctors believe that is true Vogt et al. Addiction 2005;100:1423-1431

  14. Lack of efficacy and convictionthat are useful Vogt et al. Addiction 2005;100:1423-1431

  15. What is the american physicians convictionthat they can help the patients? • Survey of psychiatrists, family practitioners, ob/gyns, and general internists (~3000 returned surveys)1 Percent of Physicians Reporting “High” Levels of Confidence in … 64% Discussing Treatment Options 63% Assessing Willingness to Quit 60% Selecting Appropriate Medications 44% Motivating Patients 34% Referring to Others 33% Monitoring Patient Progress 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% • Adapted from: American Legacy Foundation. Physician Behavior and Practice Patterns Related to Smoking.AAMC; 2007. Available at: http://www.aamc.org/workforce/smoking-cessation-full.pdf

  16. Barriers of treatment according to guidelines at 2008-20091 • Lack of knowledge in the quick identification of smokers • Lack of knowledge related to therapy (efficacy, as to be used) • Lack of institutional support, clinical inadequate • Lack of time • Lack of "training” for other treatments • Limited insurance coverage for interventions • Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline.USDHHS. PHS; May 2008. Available at: www.surgeongeneral.gov/tobacco/default.htm

  17. Advice versus offer of treatment 1 Analysis by Aveyard -2009

  18. Current treatment usage in England Low take-up of BehSup and prescription medications Data from Smoking Toolkit Study 2009. www.smokinginengland.info 19

  19. What means for the doctor • From those who are addressed to advisory services… 6 of 7 failure /one year

  20. If prescribing pharmacotherapy with minimal advice • Of those who received minimal advice with prescription 12 of 13 failure/ one year

  21. Negative reaction of the patient Vogt et al. Addiction 2005;100:1423-1431

  22. From where is coming the conviction that the evolition is enough? • Of all the ex-smokers … 7 of 10 were stopped without any medical intervention

  23. Hospital readmission in intensive (ISI) vs Usual care (UC) smoking cessation groups All-cause mortality in intensive (ISI) vs usual care (UC) smoking cessation groups A comparison of the effect of an intensive in-hospital smoking cessation programme for patients admitted with acute cardiovascular conditions. A dramatic reduction in readmission and all-cause mortality is observed over a 24-month follow-up period. Adapted with permission from: Mohiuddin SM et al. Chest 2007;131:446-452

  24. Barriersgenerated by patients

  25. Physician – Most ImportantSource of Health Information Source x Trust x Action = Behavioral Change US Germany Source Trust Action Source Trust Action Doctor 67 .83 .98 55 Pharmacist 27 .65 .90 16 Family 42 .42 .83 15 Internet 36 .21 .52 4 Media 22 .11 .48 1 Government 10 .20 .58 1 Doctor 81 .78 .93 59 Pharmacist 37 .50 .70 13 Family 68 .52 .69 24 Internet 46 .23 .29 3 Media 46 .16 .29 2 Government 7 .14 .22 2 South Africa UK Source Trust Action Source Trust Action Doctor 53 .78 .91 38 Pharmacist 43 .65 .86 24 Family 42 .43 .73 13 Internet 23 .27 .40 3 Media 23 .21 .34 2 Government 5 .12 .26 <1 Doctor 67 .76 .91 46 Pharmacist 51 .61 .84 26 Family 69 .52 .78 28 Internet 42 .17 .41 3 Media 36 .15 .37 2 Government 19 .17 .40 1 Canada Japan Source Trust Action Source Trust Action Doctor 58 .81 .95 45 Pharmacist 28 .69 .92 18 Family 36 .38 .77 11 Internet 30 .17 .47 2 Media 20 .15 .49 2 Government 10 .21 .54 1 Doctor 66 .55 .73 27 Pharmacist 15 .34 .63 3 Family 52 .36 .63 12 Internet 35 .19 .36 2 Media 48 .21 .53 5 Government 9 .21 .47 <1 26 McGee M. World Medical Journal. 2003;1:18-19.

  26. Relative Importance ofRelationships Is This Relationship Extremely/Very Important to You? (% Affirmation) US Germany 91 Family 95 Family Doctor 79 Doctor 72 10 Spiritual Advisor 56 Spiritual Advisor Pharmacist 48 Pharmacist 34 64 Co-worker 51 Co-worker 35 Financial Advisor 43 FinancialAdvisor UK South Africa Family 92 95 Family Doctor 63 80 Doctor Spiritual Advisor 21 70 Spiritual Advisor Pharmacist 26 54 Pharmacist Co-worker 63 68 Co-worker Financial Advisor 36 60 Financial Advisor Canada Japan Family 71 94 Family Doctor 55 76 Doctor 17 Spiritual Advisor 32 Spiritual Advisor 44 Pharmacist 39 Pharmacist 46 Co-worker 40 Co-worker 35 Financial Advisor 19 Financial Advisor McGee M. World Medical Journal. 2003;1:18-19.

  27. 70% 75% 88% 66% 6% How patients perceive the discussion with the doctor about smoking It was the doctor’s job to talk about smoking today The doctor was right to talk about smoking today It was OK for the doctor to talk about smoking today The doctor’s advice was helpful I wish the doctor had not mentioned smoking today 0% 20% 40% 60% 80% 100% Percentage Agreement • Adapted from Coleman T and Wilson A. Br J Gen Pract 1999; 49:557-8.

  28. Patient expectations Vogt et al. Addiction 2005;100:1423-1431

  29. 90% Smokers’ expectations 80% Projected from previous experience 70% 60% Expectation Gap 50% Percentage No Longer Smoking 40% 30% 20% 10% 0% 0 1 2 5 10 20 # of Years From Now Differences between expectations and reality Adapted from Jarvis MJ et al. BMJ 2002;324:608

  30. Plasma levels of nicotine from 0 to 24 hours 4 mg nicotine gum (peakla 12 ng) falls between to 0 and 6 am Smoking a cigarette per hour Patch –sanguine varying levels depending on dosage and type of patch 21 mg in 24h Comfort zone of addicted smoker Plasma nicotine (ng/ml) 10 6 8 12 2 4 6 8 10 12 2 4 6 AM AM Noon Midnight Slide Source: Dr. P. Selby (CAMH) and Dr. A. Pipe (Ottawa Heart Institute)

  31. Lack of identification and documentation system related to smoking 30% of smokers report that nobody ask for smoking status at a clinic visit1 Questions for Doctors : How can actively identify and documented patients who need help? How the system can improve the identification and documentation for such patients? 1.Reid RD et al (2009) Patient EducCouns 76:99-105 32

  32. 20% Were given self-help materials, information, or referral 21% Never talked with HP about smoking Feel comfortable asking their HP for help Actually do ask their HP for help 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage American smoker’s perceptions on how it is helped by doctor Percent of Smoking Patients Who … • Survey of 1012 adult smokers1 79% Were satisfied with help received from HP 52% Think their HP should help 45% Are concerned or very concerned about their health 44% Were recommended pharmacotherapies by their HP 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percentage Percent of Smoking Patients Planning to Quit (Next 30 Days) Who … 83% 53% • Adapted from American Legacy Foundation. Smoker’s Perceptions of Healthcare Providers.2009. Press release available at: http://www.americanlegacy.org/3049.aspx

  33. Nicotine Withdrawal Symptoms Hughes et al. Addiction. 1994;89:1461-70.

  34. Prevalence of Smoking in Psychiatric & Substance Use Disorders Non-psychiatric/-substance use disorders Substance use disorders Psychiatric disorders 100 80 60 Smoking prevalence (%) 40 20 0 SZ Alcohol Opioid Cocaine PD MDD BPD OCD PTSD Gen US pop Clinical group SZ, schizophrenia; BPD, bipolar disorder; MDD, major depressive disorder; PD, panic disorder; OCD, obsessive-compulsive disorder; PTSD, post-traumatic stress disorder Kalman et al (2005) Am J Addict 14(2): 106-123

  35. Prevalence of Smoking in Depressed Patients in United Kingdom Depressed patients General population 56% 26% 44% 74% Nonsmokers Current smokers Farrell et al (2003) Int Rev Psychiatry 15(1-2): 43-49; Mackay et al (2006) The Tobacco Atlas 2nd ed

  36. Smoking & Suicide Risk P<.001 5 4.3 4 Relative riska 3 2.5 2 1.4 1.0 1 0 Never smokers Ex-smokers 1-14 (n=1333) 15 (n=2241) Cigarettes/day: current smokers aAdjusted for time period, age, alcohol, and marital status Miller et al (2000) Am J Public Health 90(5): 768-773

  37. Smoking cessation and relapse prevention programs for pregnant women For every $1 invested:$3 are savedin health-related costs! Value in Health 2008;11(2):180-190

  38. Barriers related to system

  39. Can Political and Social Changes Affect Smoking Prevalence? Adult Per Capita Cigarette Consumption & Major Smoking and Health Events – United States, 1900–2005 • Giovino GA. Presented at National Conference on Tobacco or Health 2009. Available at: http://www.impacteen.org/generalarea_PDFs/NCTOH2009_CBtalk-6-10-09-Giovino-FINAL.pdf

  40. Tobacco-related deaths result in lost economic opportunities. Half of all tobacco-related deaths occur during the prime productive years. World Health Organization: The cost attributable to tobacco use 2006

  41. Priorities - wrongchosen ? OMS : 1-2 billioane US$ budget & 1000 population @ headquarters cat from budget for chronic disease 3 %

  42. Many of the world’s one billion smokers want to quit Cessation programs are fully available in only nine countries, with 5% of the world’s population. WHO Report on the Global Tobacco Epidemic, 2008

  43. Waste of funds– single official marketed drug In Indonesia, the population with lowest income spend 15% of total income on tobacco The poorest households in Bangladesh spend 10 times more on tobacco than education Tobacco Control 2001;10(3):212-217

  44. Prices and smugglingCapital.ro-7.01.2010

  45. Cost benefit of smoking cessation 12-month employer savings (in US $) pernon-smoking employee:Varenicline: $ 541Bupropion: $ 270 Placebo: $ 82Due to improved quit rates, Varenicline provides greater economic benefit despite increased initial cost. J Occup Environ Med 2007;49(4):453-460

  46. Cost Effectiveness Smoking Cessation $ 2,000 – 6,000 Rx of Hypertension $ 9,000 – 26,000 Rx of Hyperlipidemia $ 50,000 – 196,000 per life-year saved: Benowitz NL Prog Cardiovasc Dis 2003;46:91-111

  47. The poor are much more likely than the rich to become ill and die prematurely from tobacco-related illnesses, creating greater economic hardship. World no tobacco day 2004 materials. World Health Organization

  48. Barriers which depend on tobacco industry

  49. Myths industry maintained

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