Smoking Cessation

1. Kevin Scott Ferentz, M.D. Associate Professor Department of Family Medicine University of MD School of Medicine Smoking Cessation

2. Cigarette smoking is the single most important cause of disease and premature death in the United States

3. Cigarette-related deaths • 440,000 per year • 12 million dead since first surgeon general’s report in 1964 • Smokers die 13-14 years earlier • Medical costs: $ 75 billion • Lost productivity: $ 82 billion • Costs: $ 40/pack

4. Smoking in the U.S. - 2006 • 21% of adults (43% in 1966) • Kentucky 27.4%, Utah 10.5% • men (24%) women (18%) • < HS education 3X likely than w/ college degree • rate dropped little in 1990’s • Rate dropping by < 1% per year • 1.3 million quit each year • 3,000 teens start each day • adolescent smoking may be dropping • more ex-smokers than current smokers • 2010 goal: 12% smokers

5. Current cigarette smoking among HS students by sex, frequency, and grade level: US, 2003 Frequent smoking Male Grade 9 Grade 10 Grade 11 Grade 12 Female Grade 9 Grade 10 Grade 11 Grade 12 0 10 20 30 40 Percent Current smoking = smoked on 1 or more days of the 30 days preceding survey; Frequent smoking = smoked on 20 or more of the 30 days preceding the survey. Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004

6. The politics of tobacco • States that grow tobacco: • lowest taxes, highest rates of smoking • Most Tobacco Restitution Funds are NOT going to tobacco control • California: 1988 • 23% smoking rate • Voters approve 25¢ tax for anti-smoking campaign • California: 2003 • 15% smoking rate • 13% of HS students smoke (22% nationally) • Phillip Morris profits up 10% in 2004

7. Smoking worldwide • 1.3 billion smokers • Expected to rise to 1.7 in 2025 • Kills 5 million yearly • 1 death every 6.5 seconds • May double in 20 years • 84% of smokers are in developing countries • 95 billion cigarettes sold in India each year! World Health Organization – 2004

8. Increased Cancer Risk • 90% of lung cancer deaths • 40% of all cancers • mouth, larynx, esophagus, stomach • kidney, bladder • Pancreas • Cervix • Acute myeloid leukemia • more women die of lung than breast cancer!

9. Heart disease • leading cause of death • smoking is major risk factor • 3 times more likely to die of heart disease • step-wise increase with other risk factors

10. Lung Disease • 90% of COPD deaths • asthma • bronchitis • pneumonia

11. Female smokers • infertility • earlier menopause • osteoporosis • birth control pills • vaginitis

12. Pregnant smokers • spontaneous abortion • placenta previa • placental abruption • premature rupture of membranes • preterm labor • restricted fetal growth • increased fetal respiratory rate • placental abnormalities

13. Children of smokers • respiratory illness • SIDS • cognitive development • behavioral development • cancer • increased risk of smoking

14. Involuntary smoking is a cause of disease in non-smokers

15. Smokeless tobacco • “spit” tobacco • cancer of mouth, pharynx, esophagus • tooth discoloration • gingival recession • periodontal bone destruction • death from juice ingestion

16. Other problems • fire accidents • gingivitis • skin wrinkles • impotence • decreased stamina • colds, flu

17. Heart disease Lung disease – COPD, asthma Cancer Lung, ENT, pancreas Cervix Skin (squamous cell) Vascular disease – impotence, AAA Stroke Cataracts Macular degeneration Gum disease Tooth decay Osteoporosis Wound healing Anxiety & Depression Miscarriage SIDS Hearing loss Rheumatoid arthritis Lupus Dementia Multiple sclerosis Health effects from smoking

18. alcohol cocaine crack heroin homicide suicide car accidents fires AIDS Smoking kills more people each year than C O M B I N E D!!!

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20. © What’s in a cigarette? • 4,000 chemicals • tar • carbon monoxide • nicotine

21. “...cigarettes and other forms of tobacco are addicting in the same sense as are drugs such as heroin and cocaine.” C. Everett Koop, MD 1988 Surgeon General’s Report

22. Criteria for addicting drug • Dependence • Tolerance • Withdrawal Nicotine yield/cig increased 11% from 1998-20051 1Harvard School of Public Health, 2007

23. Nicotine - immediate effects sympathetic stimulation parasympathetic stimulation feelings of: stimulation better concentration pain tolerance

24. The effects on health from smoking are reversible if a smoker stops smoking

25. Health benefits after quitting • cough, DOE resolve in weeks • exercise tolerance improves rapidly • bladder cancer: 50% reduction in 5 years • lung cancer: 50% reduction in 10 years • heart disease: 50% reduction in 1 year! • No increased risk of heart disease by 10-15 yrs • vascular disease: 50% reduction in 5 years • mortality rates same as never smokers by 10-15 yrs

26. How are we doing with our patients? • 1991: • < 50% of patients reported ever being told to stop1 • 1998: • 67% Ask, 74% Advise, 35% Assist, 8% Follow-up2 • 2003: (patients that got prescription)3 • 36% told to set quit date, 25% counseled, 13% advised to follow up Many smokers do not get the advice and help they need!!! 1Frank,E., Winkleby, M.A.,Altman, D.G., et al. JAMA 1991;266:3139-3134. 2Goldstein MG, et al. Preventive Medicine. 27(5 Pt 1):720-9, 1998 Sep-Oct. 3Solberg LI, et al. Archives of internal medicine, 2005;165:656

27. Why counsel all smokers? • 90% want to quit • minimal physician input almost doubles quit rate1 • most quit without intensive assistance once they make the decision • moving patients through the process2 • precontemplation • contemplation • preparation • action • maintenance 1Cochrane Database of Systematic Reviews. 2004 2J of Cons & Clin Psych. 51(3):390-5, 1983 Jun

28. Physician influence • position of authority • credible source • personalize health effects • face-to-face counseling • multiple contacts • good role models

29. Patient resources • printed materials (still need counseling) • National Cancer Institute(1-800-4-CANCER) • www.smokefree.gov • Smokingstopshere.com • 1–800–QUIT–NOW (quit lines improve chances of quitting)

30. A minimum amount of time spent with more smokers will yield more ex-smokers than intensive efforts with a few

31. Minimum counseling • firm, unambiguous advice • written materials • set a quit day • set follow-up visit • (or warn patient you will ask about progress at a future visit)

32. Factors which influence smokers to make an attempt to quit

33. Influence to quit • firm, unambiguous advice • “as your doctor, I’m telling you to QUIT!” • personalize damaging health effects • effects reversible with quitting

34. Personalizing effects - history • shortness of breath • cold hands and feet • fatigue • decreased stamina • colds and flu • bronchitis, sinusitis • teeth, gums • kids’ problems

35. Personalizing effects - physical • gingivitis • tar stains • bad breath • diminished breath sounds • wheezing, rhonchi • peripheral pulses • fundal height • wrinkling

36. Personalizing effects - labs • carboxyhemoglobin • pulmonary function tests • peak flow • chest x-ray

37. Influence to quit • firm, unambiguous advice • “as your doctor, I’m telling you to QUIT!” • personalize damaging health effects • effects reversible with quitting • non-health reasons

38. Non-health reasons for quitting • COST!!! • inconvenience • self-esteem • role model

39. Influence to quit • firm, unambiguous advice • “as your doctor, I’m telling you to QUIT!” • personalize damaging health effects • effects reversible with quitting • non-health reasons • confidence

40. Building confidence • express your confidence • millions of others have quit • more ex-smokers than smokers • most try many times before succeeding • past attempts are learning experiences • ways to deal with physical and psychological dependence

41. Influence to quit • firm, unambiguous advice • “as your doctor, I’m telling you to QUIT!” • personalize damaging health effects • effects reversible with quitting • non-health reasons • confidence • address concerns

42. Common concerns • Withdrawal • short lived • Cravings • last 3-5 minutes, diminish rapidly • Tension • validate, normalize • find other ways to cope • Weight gain - not inevitable! • 1/3 gain: 5-8 lbs.

43. At a minimum, tell all patients how important you feel it is that they quit(not cut down)

44. Refer patients who are interested to a group program

45. Accentuate the positive aspects of quitting rather than dwelling on the dangers of continuing to smoke

46. Factors which help smokers quit once the decision is madeBehavior Modification

47. Components of addiction • physiological • psychological • behavioral

48. Behavior modification • review reasons for quitting (index card) • identify triggers (4 day diary) • plans to avoid or cope with each trigger

49. Trigger after meals on the phone in the car at desk tension coffee breaks other smokers crisis Technique leave table draw chew gum carrot sticks deep breathing juice non-smokers self-talk Sample plan

50. Behavior modification • review reasons for quitting (index card) • identify triggers (4 day diary) • plans to avoid or cope with each trigger • change habit: packs only, different brands • develop support system (tell everyone) • self rewards (day, week, month, year) • written commitment to quit day