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HARM REDUCTION-SMOKING CESSATION

HARM REDUCTION-SMOKING CESSATION. Funda ÖZTUNA, MD Dept of Chest Disease and Tuberculosis, Trabzon 13th Annual Congress of the Turkish Thoracic Society , 5-9 May 010, İstanbul. CONFLICT INTEREST 2007-2010. 2008- ERS congress- support ( Actelion)

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HARM REDUCTION-SMOKING CESSATION

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  1. HARM REDUCTION-SMOKING CESSATION Funda ÖZTUNA, MD Dept of Chest Disease and Tuberculosis, Trabzon 13th Annual Congress of the Turkish Thoracic Society , 5-9 May 010, İstanbul

  2. CONFLICT INTEREST2007-2010 • 2008- ERS congress- support ( Actelion) • 2008-Pulse oximeter- stock material in Our Dept (Novartis)

  3. HARM REDUCTION-Topics • Definition • Tobacco industry • Pharmaceutical industry • Medicine perspective • Result

  4. DEFINITION Tobacco harm-reduction approaches,such as the use of smokeless tobacco among smokersunwilling or unable to quit, have been considered as afeasible alternative that can potentially reduce tobaccorelated morbidity and mortality, even with continueduse of products that contain tobacco constituents Stratton K, Shetty P, Wallace R, Bondurant S, (eds): Clearing the smoke. Assessing the science base for tobacco harm reduction. Institute of Medicine. National AcademyPress, Washington, DC; 2001

  5. Nothing so bad but might have been worse

  6. RESULT HARM REDUCTION IS NOT A METHOD OF SMOKING CESSATION A clinical practice guideline for treating tobacco use and dependence: 2008 update. Am J Prev Med. 2008;35:158-76.

  7. METHODS OF HARM REDUCTION 1. Avoidance of initiation (prevention) 2. Complete cessation 3. Reduce daily cigarette consumption 4. Switch to long term nicotine replacement therapy 5.Use NRT during temporary abstinence to reduce nicotine withdrawalsymptoms 6. Switch to potentially less harmful type of smoking product 7. Switch to potentially less harmful type of smokeless tobacco

  8. Tobacco industry 1950 Medicine 1995

  9. Tobacco Industry-Harm Reduction

  10. 1954: The “Frank Statement to Smokers” • We believe the products we make are not injurious to health • We always have and always will cooperate closely with those whose task it is to safeguard the public health

  11. Statements by Industry Representatives Moreover nicotine is addictive. We are then in the business of selling nicotine, an addictive drug…. But cigarettes –…..despite the beneficient effect of nicotine, have certain unattractive side effects: They cause, or predispose to, lung cancer…. certain cardiovascular diseases..may well be truly causative in emphysema.. 1963, Addison Yeaman, Executive Vice President of Brown and Williamson Tobacco Company

  12. Statements by Industry Representatives “if our product is harmful, we’ll stop making it.” James Bowling, Vice President, Philip Morris, 1972. (Kwitny, 1972)

  13. Bernt Magnusson, Chairman of theboard of Swedish Match Swedish Match Annual General Meeting 2006:Citation from the tobacco industry: • ”We have no friends. The authorities doeverything to stop the distribution and theuse of tobacco. The government raises thetaxes. Our product is so special, it is combatted by the great majority, eventhose who make use of it” 200.000 $ for a suffering chairman

  14. Potential Reduced Exposure Products (PREPs) • Modified cigarettes • Heated/Unburned products • Smokeless tobacco products • Novel products

  15. The TRUES International Agency for Research on Cancer (IARC) 28Carcinogenic substance • Tobacco-specific nitrosamines • Benzo[a]pyrene • Formaldehyde • N-nitrosonornicotine (NNN) • 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) • Arsenic • Nickel compounds • Polonium-210 • Uranium-235 • Uranium-238 • Beryllium • Cadmium • Chromium IARC Monographs 2008

  16. RİSKS • Oral Cavity Cancer • Pharyngeal ve laryngeal cancers • Pancreas, stomach cancers • Cardiac harmfull effects • Fetus harmfull effects . Cullen JW, et al.Health consequences of using smokeless tobacco: summary of the Advisory Committee’s report to the Surgeon General. Public Health Rep 1986; 101:355–73. Bolinder G, et al. Smokeless tobacco use and increased cardiovascular mortality among Swedish construction workers. Am J Public Health 1994;84:399–404. Foulds J, et al. Efect of smokeless tobacco (snus) on smoking and public health in Sweden [review]. Tob Control 2003;12:349–59 Luo J, et al.Oral use of Swedish moist snuf (snus) and risk for cancer of the mouth, lung, and pancreas in male construction workers: a retrospective cohort study. Lancet 2007; 369:2015–20 Roosaar A, et al. Cancer and mortality among users and nonusers of snus. Int J Cancer 2008 ;123:168–73. Bofetta P, et al. Smokeless tobacco and cancer. Lancet Oncol 2008;9:667–75.

  17. Smokeless tobacco is not qualified as an acceptable alternative to smoking • Medical; due to the significant health risks • Pharmacological;due to it’s high addictive potential • Ethical; due to the industrial efforts to continue to recruit young new addicts

  18. Pharmaceutical Industry • Selling product on a short-term basis • İncreased cessation rate on medium -term • Future?

  19. MEDİCİNE-HARM REDUCTION

  20. Treating Tobacco Use andDependence: 2008 Update Noncigarette Tobacco Users • Smokeless tobacco users should be identifed, stronglyurged to quit, and provided counseling cessationinterventions. (Strength of Evidence = A) • Recommendation: Clinicians delivering dental health services should provide brief counseling interventions to all smokeless tobacco users. (Strength of Evidence = A) • Recommendation: Users of cigars, pipes, and other noncigarette forms of smoking tobacco should be identifed, strongly urged to quit, and ofered the same counseling interventions recommended for cigarettesmokers. (Strength of Evidence = C)

  21. Treating Tobacco Use and Dependence: 2008 Update Like cigarette smoking, the use of smokeless tobacco, such as chewingtobacco, snuff, or moist snuff, produces addiction to nicotine and has serioushealth consequences.742-744 Smokeless tobacco use was reported among4 percent of adult men, but less than 1 percent of women in 2005.591,745Health risks from these products include abrasion of teeth, gingival recession,periodontal bone loss, leukoplakia, and oral and pancreatic cancer.745,746 Thus, the use of smokeless tobacco is not a safe alternative tosmoking,747 nor is there evidence to suggest that it is effective in helping smokers quit.Evidence shows that counseling treatments are effective in treating smokelesstobacco users.748-750 Therefore, clinicians should offer quitting adviceand assistance to their patients who use tobacco, regardless of the formulationof the tobacco product. Some information may be particularly relevant in the treatment of smokeless tobacco use. For instance, a large majorityof moist snuff users have identifiable orallesions, and emphasizing this informationduring an oral exam may be useful in motivating a quit attempt.A close review of the literature showed that dental health clinicians (e.g.,dental hygienists) delivering brief advice to quit using smokeless tobacco,in the context of oral hygiene feedback, can increase abstinence rates.250,751Cigar smokers are at increased risk for coronary heart disease; COPD;periodontitis; and oral, esophageal, laryngeal, lung, and other cancers;with evidence of dose-response effects.752-756 The prevalence of cigar smoking was 5 percent for men and less than 1 percent for women.590 Althoughcigarette sales have declined over the last decade, cigar sales have increasedin the United States, increasing 15.3 percent in 2005,757 and sales of “littlecigars” were at an all-time high in 2006.758 Cigar smokers are known to discountthe health effects of cigar smoking, believing it to be less detrimental than cigarettes.752,759 Clinicians should be aware of and address the use of other noncigaretteobacco products, including pipes, water pipes (also known as hookahs andnarghile), cigarillos, loose tobacco, bidis, and betel quid. The use of cigars,pipes, and bidis is associated with cancers of the lung, stomach, oral cavity,larynx, and esophagus.760 Further, the evidence is mixed as to whether ornot individuals who use noncigarette tobacco products, either alone or inaddition to cigarettes, find it more or lessdifficult, in comparison to cigarettesmokers, to become abstinent from tobacco.761,762 Tobacco Use Medications. Current evidence is insufficient to suggest thatthe use of tobacco cessation medications increases long-term abstinenceamong users of smokeless tobacco. Studies conducted to date with variousmedications have not shown that they increase abstinence rates in this population.750,751,763,764

  22. METHODS OF HARM REDUCTION 1.Reduce daily cigarette consumption 2. Switch to long term nicotine replacement therapy 3. Use NRT during temporary abstinence to reduce nicotinewithdrawal symptoms

  23. Reduce Daily Cigarette Consumption Mortality rates have no contributed Risks of • Cardiovasculer • Lung • Cancer • Others ?

  24. Cohort Studies Godtfredsen NS, et al. Smoking Reduction, Smoking Cessation, and Mortality: A 16-year Follow-up of 19,732 Men and Women from the Copenhagen Centre for Prospective Population StudiesAm J Epidemiol 2002;156:994–1001

  25. Health consequences of reduced dailycigarette Aage Tverdal and Kjell Bjartveit .2006;15;472-480 Tob. Control

  26. Level of serum thiocyanate Aage Tverdal and Kjell Bjartveit .2006;15;472-480 Tob. Control

  27. All Causes Men Women

  28. Cardiovasculer Diease Men Women

  29. Smoking releated cancers Men Women

  30. CONCLUSION • In both sexes, a reduction in cigaretteconsumption by 50%was not associated with a markedly lower risk of all-causemortality and, specifically, of dying from cardiovasculardisease or smoking-related cancer. • Accordingly, a reductionin consumption does not seem to bring about harmreduction.

  31. Switch to Nicotine Replacement Therapy

  32. Switch to Nicotine Replacement Therapy • Safe? • Successful?

  33. Nicotine replacement therapy for long-term smokingcessation: a meta-analysis Etter JF, Stapleton JA. Nicotine replacement therapy for long-term smoking cessation: a meta-analysis. Tobacco Control 2006;15:280–5.

  34. EFFECTS OF NRT ON OUIT RATES

  35. Effect of NRT treatment for less than 12 months on relapse after 12 months of smoking cessation Etter JF, Stapleton JA. Nicotine replacement therapy for long-term smoking cessation: a meta-analysis. Tobacco Control 2006;15:280–5.

  36. RESULT HARM REDUCTION IS NOT A METHOD OF SMOKING CESSATION

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