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Smoking:Smoking:The Talk You’ve Never The Talk You’ve Never

HeardHeardMichael B. Honan, MD

CardioVascular Associates, PC

Brookwood Medical Center

December 30, 2008

DisclosuresDisclosures

NoneNone

ObjectivesObjectives I want to convince you that smoking cessation is:I want to convince you that smoking cessation is:

Far and away the most impactful thing smokers Far and away the most impactful thing smokers can do to help their long-term health and life can do to help their long-term health and life expectancy.expectancy.

““This is much more important to how long you live and This is much more important to how long you live and how healthy you are than whether we open your artery how healthy you are than whether we open your artery or not.”or not.”

I want you to have the information needed to I want you to have the information needed to give you the greatest chance of success in this give you the greatest chance of success in this endeavorendeavor. . Motivation is the single biggest Motivation is the single biggest factor determining whether or not someone factor determining whether or not someone will quit smoking.will quit smoking.

Approaches to the Approaches to the DiscussionDiscussion

• Be sure they know that you understand that:Be sure they know that you understand that:• This is their decision,This is their decision,• that your role is only to give them the information that your role is only to give them the information

that you have that they might benefit from, andthat you have that they might benefit from, and• that you will do what you can for them regardless that you will do what you can for them regardless

of what they choose to do.of what they choose to do.• Your message might not resonate until the 6Your message might not resonate until the 6thth or or

77thth time you have this conversation, but it is your time you have this conversation, but it is your role to allow them the opportunity to reconsider role to allow them the opportunity to reconsider their decision to smoke.their decision to smoke.

• They may not succeed in quitting until their 6They may not succeed in quitting until their 6thth or or 77thth attempt. attempt.

Public Health Public Health Service Guidelines – Service Guidelines –

The 5A ModelThe 5A Model1.1. AAsk about smoking.sk about smoking.

2.2. AAdvise one to quit.dvise one to quit.

3.3. AAssess willingness to quit.ssess willingness to quit.

4.4. AAssist those willing to quit.ssist those willing to quit.

5.5. AArrange for follow-up.rrange for follow-up.

Fiore MC, et al. Treating tobacco use and dependence: clinical practice guideline.Rockville (MD): US Dept Health Human Svcs Public Health Svc; 2000. Also 2008 Update.

Approaches to the Approaches to the DiscussionDiscussion

• Help them to understand that they can quit.Help them to understand that they can quit.• There are more former than current smokers in There are more former than current smokers in

the US. the US. • Up to 85% of smokers after MI have quit smoking.Up to 85% of smokers after MI have quit smoking.

• It’s never “too late” to quit smoking.It’s never “too late” to quit smoking.• The older the smoker and the longer the The older the smoker and the longer the

smoking duration, the greater the chances of smoking duration, the greater the chances of quitting.quitting.

• Encourage them to have this conversation Encourage them to have this conversation with themselves.with themselves.• ““List the reasons you want to continue to smoke, List the reasons you want to continue to smoke,

and the reasons you might not want to start back.”and the reasons you might not want to start back.”

Individualize your discussion for each patient.Individualize your discussion for each patient.

Smoking and Smoking and MortalityMortality

In 1928, smoking linked to lung In 1928, smoking linked to lung cancercancer11..

In 1938, smoking linked to mortality In 1938, smoking linked to mortality overalloverall22..

The first Surgeon General’s Report The first Surgeon General’s Report labeled smoking “the single most labeled smoking “the single most important source of preventable important source of preventable morbidity and premature mortality.” morbidity and premature mortality.” in 1964.in 1964.1. Lombard HL, Doering CR. N Engl J Med 1928;198:481-7.

2. Pearl R. Science 1938;87:216-7.

Surgeon General’s Surgeon General’s Report May 2004Report May 2004

438,000 deaths per year- still the #1 438,000 deaths per year- still the #1 cause of preventable death in the UScause of preventable death in the US.. 19% of all deaths!!!19% of all deaths!!!

Reduces lifespan of the average Reduces lifespan of the average smoker by:smoker by: 13.2 years for males13.2 years for males 14.5 years for females 14.5 years for females

5,522,257 years of potential life lost 5,522,257 years of potential life lost in the US in 2001. in the US in 2001.

Deaths Attributed to Deaths Attributed to SmokingSmoking

Lung Cancer

Other Cancers

COPD

Heart Disease

Stroke

Other

Secondhand Smoke

Morbid Mortal Wkly Rep 2003;52:842-4.

Risk FactorsRisk Factors

UnmodifiableUnmodifiable AgeAge Family history of Family history of

early CADearly CAD Male genderMale gender Genetic factorsGenetic factors African-AmericanAfrican-American

ModifiableModifiable Cigarette smokingCigarette smoking HypertensionHypertension Cholesterol-HDL, LDL,Cholesterol-HDL, LDL, TriglyceridesTriglycerides DiabetesDiabetes OverweightOverweight Poor diet Poor diet Lack of regular Lack of regular

exerciseexercise Cocaine/crack useCocaine/crack use

Cardiovascular Risk Cardiovascular Risk FactorsFactors

Smoking > 1 ppdSmoking > 1 ppd

Smoking Smoking >> 1 ppd 1 ppd

Weight Weight >> 129% ideal vs 129% ideal vs << 112% 112%

Cholesterol > 268 vs < Cholesterol > 268 vs < 219219

Systolic BP > 150 vs Systolic BP > 150 vs << 130130

Diastolic BP > 94 vs Diastolic BP > 94 vs << 80 800 0.5 1 1.5 2 2.5 3 3.5

Relative Risk of Major Coronary Events

8422 Men Age 40-64 Followed for 72,011 person-years

The Pooling Project Research Group. J Chron Dis 1978;31:201-306.

There are also interactions between risk factors.

Cardiovascular Cardiovascular EffectsEffects

Impairs endothelial function – vasoconstriction.Impairs endothelial function – vasoconstriction. Pro-thromboticPro-thrombotic

Increases fibrinogen, hs-CRP, and homocysteine Increases fibrinogen, hs-CRP, and homocysteine levels.levels.

Reduces anti-thrombin III.Reduces anti-thrombin III. Increases platelet aggregation.Increases platelet aggregation.

Causes catecholamine release.Causes catecholamine release. Increases lipolysis, fatty acid release, VLDL levels.Increases lipolysis, fatty acid release, VLDL levels. Lowers HDL cholesterol.Lowers HDL cholesterol.

Reduces the oxygen content of blood.Reduces the oxygen content of blood. Carbon monoxide binds irreversibly to hemoglobin.Carbon monoxide binds irreversibly to hemoglobin. Impaired pulmonary function – raises A-a gradient.Impaired pulmonary function – raises A-a gradient.

Bazzano LA. Ann Intern Med 2003;138:891-7.

Cardiac EffectsCardiac Effects AtherosclerosisAtherosclerosis

Promotes coronary plaque formation.Promotes coronary plaque formation. Promotes plaque rupture/ acute coronary syndromes.Promotes plaque rupture/ acute coronary syndromes. Promotes premature coronary bypass closure and Promotes premature coronary bypass closure and

restenosis.restenosis. Reduces coronary blood flow and promotes Reduces coronary blood flow and promotes

coronary vasospasm – cath lab demoscoronary vasospasm – cath lab demos1,21,2.. Nicotine increases oxygen utilization and demand Nicotine increases oxygen utilization and demand

by increasing heart rate & BP – increases by increasing heart rate & BP – increases ischemiaischemia33..

Arrhythmias-PVCs, APCs, atrial fib, MAT, VT, V-fib.Arrhythmias-PVCs, APCs, atrial fib, MAT, VT, V-fib. Cardiomyopathy independent of atherosclerosisCardiomyopathy independent of atherosclerosis44..

1. Kaijser L, Berglund B. Clin Physiol 1985;5:541-52. 2. Maouad J, et al. CatheterCardiovasc Diagn 1986;12:366-75. 3. Wolk R. J Amer Coll Cardiol 2005;45:910-4.4. Hartz AJ, et al. N Engl J Med 1984;311:1201-6.

Cardiovascular Cardiovascular EffectsEffects

33.5% of smoking-related deaths33.5% of smoking-related deaths11.. Coronary artery disease (X 2.5)Coronary artery disease (X 2.5)22 – angina, – angina,

myocardial infarction, arrhythmias, sudden myocardial infarction, arrhythmias, sudden death, heart failure.death, heart failure.

Cerebrovascular disease – stroke (X 3),Cerebrovascular disease – stroke (X 3),33 hemorrhagic stroke (X 3.29)hemorrhagic stroke (X 3.29)44, and TIA., and TIA.

Peripheral vascular disease (X 7.3Peripheral vascular disease (X 7.3)5 –)5 – claudication, leg ulcers, impaired wound claudication, leg ulcers, impaired wound healing, gangrene, aneurysms of aorta and healing, gangrene, aneurysms of aorta and other vessels, venous insufficiency (X 2.4).other vessels, venous insufficiency (X 2.4).66

Interaction with other risk factors – diabetes, Interaction with other risk factors – diabetes, lipids, hypertension, estrogen, genetics.lipids, hypertension, estrogen, genetics.

1. Morbid Mortal Wkly Rep 2003;52:842-4. 2. The Pooling Project Research Group. J Chron Dis 1978;31:201-306. 3. Hankey GJ. J Cardiovasc Risk 1999;6:207-11.4. Kurth T, et al. Stroke 2003;34;2792-5. 5. Fowler B, et al. Aust NZ J Publ Health2002;26:26:291-24. 6. Gourgo S, et al. Am J Epidemiol 2002;155:1007-15.

Relative Risk Relative Risk CardiovascularCardiovascular

1.01

3.07

1.33

1.04

1.22

1.64

2.07

6.21

2.44

3.27

1.78

2.8

0 1 2 3 4 5 6 7

Other Arterial Disease

Aortic Aneurysm

Atherosclerosis

Cerebrovascular Disease

Other Heart Disease

Ischemic Heart Disease

Relative Risk of Cardiovascular Events

CurrentFormer

http://apps.nccd.cdc.gov/sammec/edit_risk_data.asp

Smoking Cessation Smoking Cessation after MIafter MI

Occurred in 56.2% at 6 months and 56.8% at Occurred in 56.2% at 6 months and 56.8% at a year among 19 hospitals in the Premier a year among 19 hospitals in the Premier Registry. Registry. 11

Results in a 36-46% reduction in mortality.Results in a 36-46% reduction in mortality.2,32,3

Reduction in recurrent nonfatal MI.Reduction in recurrent nonfatal MI. Better control of other cardiovascular risk Better control of other cardiovascular risk

factors.factors. Better functional status.Better functional status. Thus smoking cessation counseling a CMS, Thus smoking cessation counseling a CMS,

JCAHO performance measure.JCAHO performance measure.1. Reeves GR, et al. 1. Reeves GR, et al. Arch Intern Med Arch Intern Med 2008;168:2111-7. 2. 2008;168:2111-7. 2.

Critchley, et al. Critchley, et al. Cochrane Database Syst Rev. Cochrane Database Syst Rev. 2003:CD003041.doi:10.1002/14651858CD003041. 2. Wilson K, 2003:CD003041.doi:10.1002/14651858CD003041. 2. Wilson K, et al. et al. Arch Intern Med Arch Intern Med 2000;160:939-44.2000;160:939-44.

ACC/AHA 2007 STEMI ACC/AHA 2007 STEMI Guidelines Secondary Guidelines Secondary

PreventionPrevention Ask, advise, assess, and assist patients to Ask, advise, assess, and assist patients to

stop smoking – I (B)stop smoking – I (B) Clopidogrel 75 mg daily:Clopidogrel 75 mg daily:

PCI – I (B) PCI – I (B) no PCI – IIa (C) no PCI – IIa (C)

Statin goal:Statin goal: LDL-C < 100 mg/dL – I (A)LDL-C < 100 mg/dL – I (A) consider LDL-C < 70 mg/dL – IIa (A)consider LDL-C < 70 mg/dL – IIa (A)

Daily physical activity 30 min 7 d/wk, Daily physical activity 30 min 7 d/wk, minimum 5 d/wk – I (B)minimum 5 d/wk – I (B)

Annual influenza immunization – I (B)Annual influenza immunization – I (B)

Predictors of Predictors of Smoking Cessation Smoking Cessation

after MIafter MI PREMIER Registry- 19 centers, 639 PREMIER Registry- 19 centers, 639

smokerssmokers Discharge prescription for cardiac rehab: Discharge prescription for cardiac rehab:

OR=1.80 (1.17-2.75).OR=1.80 (1.17-2.75). Treated at a facility that offered an Treated at a facility that offered an

inpatient smoking cessation program inpatient smoking cessation program with at least one month of support after with at least one month of support after discharge: OR=1.71 (1.03-2.83).discharge: OR=1.71 (1.03-2.83).

Depressive symptoms: OR=0.57 (0.36-Depressive symptoms: OR=0.57 (0.36-0.90).0.90).

Dawood N, et al. Arch Intern Med 2008:168:1961-7.

Deaths Attributed to Deaths Attributed to SmokingSmoking

Lung Cancer

Other Cancers

COPD

Heart Disease

Stroke

Other

Secondhand Smoke

Morbid Mortal Wkly Rep 2003;52:842-4.

Respiratory Tract Respiratory Tract EffectsEffects

Causes peribronchiolar inflammation and fibrosis, Causes peribronchiolar inflammation and fibrosis, bronchospasm, increases mucosal permeability, bronchospasm, increases mucosal permeability, impairs mucociliary clearance, changes pathogen impairs mucociliary clearance, changes pathogen adherence, disrupts respiratory epithelium, adherence, disrupts respiratory epithelium, impairs immune response, carcinogenic.impairs immune response, carcinogenic.

Acute and chronic sinusitisAcute and chronic sinusitis Acute and Chronic Obstructive Pulmonary Dis (X Acute and Chronic Obstructive Pulmonary Dis (X

13.1)13.1) Asthma, emphysema (24%) chronic bronchitis (49%), Asthma, emphysema (24%) chronic bronchitis (49%),

pneumonia, interstitial lung disease, bronchiolitis, pneumonia, interstitial lung disease, bronchiolitis, pulmonary hypertension, respiratory failure, pulmonary hypertension, respiratory failure, tuberculosis (X 4.5)tuberculosis (X 4.5)

Arcavi L. Arch Intern Med 2004;164:2206-16.

Relative Risk - Relative Risk - RespiratoryRespiratory

1.36

15.64

6.8

1.75

17.1

10.58

0 5 10 15 20

Pneumonia,Influenza

Bronchitis,Emphysema

Chronic AirwayObstruction

Relative Risk

CurrentFormer


Lung Cancer Lung Cancer About 28% of smoking-attributable deaths.About 28% of smoking-attributable deaths. In 2000In 2000

in US, 87% of the 184,000 new cases of lung in US, 87% of the 184,000 new cases of lung cancercancer1 1

850,000 lung cancer deaths worldwide850,000 lung cancer deaths worldwide22.. 3000 US lung cancer deaths attributed to 3000 US lung cancer deaths attributed to

secondhand smokesecondhand smoke33.. 10-year risk for a 68yo man with a 100-10-year risk for a 68yo man with a 100-

pack-yr history is 15%.pack-yr history is 15%. Continued smoking shortens survival Continued smoking shortens survival

timetime55..1. Ctrs Dis Contr. Morbid Mortal Wkly Rep 2003;52;842-4. 2. Ezrati M. Lancet 2003;362:847-52. 3. Amer Heart Assn 2005. 5. Bach PB, et al. J Natl Cancer Inst2003;95:470-8.

Lung Cancer – Dose Lung Cancer – Dose EffectEffect

1

15

30

48

66

80

0 20 40 60 80 100

Non-Smoker

1-10

11-20

21-30

31-40

41+

Number of cigarettes/ day

Relative Risk of Lung Cancer

Wynder EL, Stellman SD. J Natl Cancer Inst 1979;62:471-7.

Cancer EffectsCancer Effects

Carcinogenic – 60 chemical Carcinogenic – 60 chemical carcinogenscarcinogens Responsible for a third of all cancer Responsible for a third of all cancer

deaths in western countries.deaths in western countries. Incidence of lung cancer deaths in the Incidence of lung cancer deaths in the

US has been steeply declining over the US has been steeply declining over the past ten years, first in men, and now in past ten years, first in men, and now in women as well.women as well.

Sacco AJ, et al. Lung Cancer 2004;Suppl 2:S3-9.

Relative Risk - Relative Risk - CancerCancer

1.3

2.1

1.7

1.1

8.7

6.3

1.2

1.5

4.5

3.4

1.86

3.27

2.72

1.6

15

2.3

2

6.8

11

23

0 5 10 15 20 25

Acute Myeloid Leukemia

Urinary Bladder

Kidney & Renal Pelvis

Uterine Cervix

Trachea, Lung, Bronchus

Larynx

Pancreas

Stomach

Esophagus

Lip, Oral Cavity, Pharynx

CurrentFormer


Gastrointestinal Gastrointestinal EffectsEffects

Chronic destructive periodontal Chronic destructive periodontal disease – the main risk factor. disease – the main risk factor. Relative risk X 5-20 vs never smokerRelative risk X 5-20 vs never smoker11..

Increased risk and severity, slower Increased risk and severity, slower healing and greater recurrence of healing and greater recurrence of gastritis, gastroesophageal reflux, gastritis, gastroesophageal reflux, peptic ulcer disease (X 3.4-4.1peptic ulcer disease (X 3.4-4.1)2.)2.

Increased Crohn’s Disease (X 2.0) and Increased Crohn’s Disease (X 2.0) and ischemic bowel.ischemic bowel.

1. Bergstrom J. Odontology 2004;92(1):1-8. 2. Mallamapalli A, et al. Med Clin N Amer 2004;1431-51.

Smoking and Smoking and InfectionInfection Cause structural changes in the respiratory tract Cause structural changes in the respiratory tract

and a decrease in immune response.and a decrease in immune response. 30% increased WBC, increased CD830% increased WBC, increased CD8++ counts, reduced IgG, IgA, counts, reduced IgG, IgA,

IgM.IgM. reduced CD4reduced CD4++ counts in bronchoalveolar fluid. counts in bronchoalveolar fluid. Inhibition of PMN chemotaxis and migration, NK cell activity.Inhibition of PMN chemotaxis and migration, NK cell activity. Decreases release of IL-1, IL-2, IL-6, TNF-α, IFN-γ.Decreases release of IL-1, IL-2, IL-6, TNF-α, IFN-γ.

2- to 5-fold increased risk of invasive pneumococcus.2- to 5-fold increased risk of invasive pneumococcus. 1.5- to 2.2-fold risk of common cold.1.5- to 2.2-fold risk of common cold. 1.4- to 2.4- fold influenza risk and more severe.1.4- to 2.4- fold influenza risk and more severe. Varicella, HPV, HIV prevalence and severity increasedVaricella, HPV, HIV prevalence and severity increased Increased risk of tuberculosis, especially important in Increased risk of tuberculosis, especially important in

underdeveloped countries.underdeveloped countries. Increased risk of meningococcal disease, bronchitis, and Increased risk of meningococcal disease, bronchitis, and

otitis media in children exposed to secondhand smoke.otitis media in children exposed to secondhand smoke.

Arcavi L. Arch Intern Med 2004;164:2206-16.

Women and Women and SmokingSmoking

Smoking reduces the average life expectancySmoking reduces the average life expectancy11 by: by: 14.5 years for females.14.5 years for females. 13.2 years for males.13.2 years for males.

Facilitates the metabolism of estrogen, increasing Facilitates the metabolism of estrogen, increasing risk of cardiovascular disease, osteoporosis (80% risk of cardiovascular disease, osteoporosis (80% higher fracture risk), cervical cancer, and higher fracture risk), cervical cancer, and wrinkles.wrinkles.

Increased susceptibility of women to develop lung Increased susceptibility of women to develop lung cancer in response to smoking which is more cancer in response to smoking which is more virulent and at an earlier age than in menvirulent and at an earlier age than in men22. In . In 2000, exceeded breast, uterine, and ovarian 2000, exceeded breast, uterine, and ovarian cancer death combined in women. ¼ of all cancer cancer death combined in women. ¼ of all cancer deaths in women. deaths in women.

Doubles the risk of DVT and PTE among OCP Doubles the risk of DVT and PTE among OCP usersusers33..

1. US Surgeon General May 2004. 2. Reuters January 31, 2005. 3. Reichert VC, et al. Med Clin N Amer 2004;88:1467-81.

Women and SmokingWomen and SmokingThe Nurses’ Health The Nurses’ Health

StudyStudy 104,519 nurses age 30-55 followed 1980-2004.104,519 nurses age 30-55 followed 1980-2004. At baseline (1980),At baseline (1980),

45.7% never smoked45.7% never smoked 26.0% past smokers26.0% past smokers 28.3% current smokers28.3% current smokers

In 2002, only 8% of those alive were current In 2002, only 8% of those alive were current smokers.smokers.

Among current smokers, Among current smokers, 64% of all deaths 64% of all deaths were directly attributable to smokingwere directly attributable to smoking. Among . Among former smokers, 28% of deaths attributable to former smokers, 28% of deaths attributable to smoking.smoking.

Kenfield SA, et al. JAMA 2008;299:2037-47.

Mortality Among Mortality Among WomenWomen

Nurses’ Health StudyNurses’ Health Study

1 1.23

2.77

1.98

2.92

3.67

4.43

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Hazard Ratio of Death

Never Past Current 1-14 15-24 25-34 >34

Smoking Status Cigarettes per Day


Causes of Death in WomenCauses of Death in WomenCardiovascular & “Unrelated Cardiovascular & “Unrelated

Cancer”Cancer”

1

1

1

1

1

1

1.1

1.1

1.1

1.1

1

1.1

3

3.3

2.8

1.7

1.6

1.8

0 1 2 3 4

VascularDisease

Coronary HeartDisease

CerebrovascularDisease

ColorectalCancer

Other Cancers

Other Causes CurrentPast Never


Causes of Death in WomenCauses of Death in WomenRespiratory & “Related Respiratory & “Related

Cancer”Cancer”

1

1

1

1

1

3.3

14

4.9

2.1

1

12

56

22

7.3

1.7

1

1.1

1.6

0 10 20 30 40 50 60

Respiratory Disease

COPD

Lung Cancer

Smoking-Related Cancers

Colorectal Cancer

Other CancersCurrentPast Never


Lung, AML, bladder, kidney, cervix, esophagus, lip, mouth, pharynx, pancreas, stomach, larynx

Smoking and Smoking and PregnancyPregnancy

Increased infertility (X 1.36), spontaneous Increased infertility (X 1.36), spontaneous abortions, ectopic pregnancies (X 1.9).abortions, ectopic pregnancies (X 1.9).

Increases prematurity and fetal death.Increases prematurity and fetal death. Low birth weight doubles.Low birth weight doubles. Increased risk of placenta previa, pre-Increased risk of placenta previa, pre-

eclampsia.eclampsia. Sudden Infant Death Syndrome – 10% of all Sudden Infant Death Syndrome – 10% of all

infant deaths.infant deaths. Negative toddler behavior –cranky, Negative toddler behavior –cranky,

restless, sick more often, learning restless, sick more often, learning problems.problems.

Morbid Mortal Wkly Rep 2002;51:i-iv,1-13.

Pregnancy & Long-Pregnancy & Long-Term Vascular Term Vascular

Damage to ChildrenDamage to Children Atherosclerosis in Young Adults study-births Atherosclerosis in Young Adults study-births

from 1970-1973, follow-up at 28.4 years.from 1970-1973, follow-up at 28.4 years. At birth offspring lighter and shorter at At birth offspring lighter and shorter at

birthbirth Heavier (p=.001) and higher SBP (p=.02) as Heavier (p=.001) and higher SBP (p=.02) as

adolescents.adolescents. Heavier (p=.004), shorter (p=.02), more Heavier (p=.004), shorter (p=.02), more

likely to smoke (p=.006) as adults.likely to smoke (p=.006) as adults. At age 28, Carotid IMT At age 28, Carotid IMT

13.4 13.4 μμm greater if mother smoked (p=0.001)m greater if mother smoked (p=0.001) 12.4 12.4 μμm greater if father smoked (p=.002)m greater if father smoked (p=.002) Greater if both smoked (p=.001)Greater if both smoked (p=.001)

Geerts C, et al. Geerts C, et al. Arterioscler Thromb Vasc Biol Arterioscler Thromb Vasc Biol 2008: DOI: 2008: DOI: 1161/ATVBAHA.108.173229.1161/ATVBAHA.108.173229.

Drug MetabolismDrug Metabolism

Enhanced clearance of:Enhanced clearance of: theophyllline, tacrine, propranolol, theophyllline, tacrine, propranolol,

diazepam, chlordiazepoxide, estrogendiazepam, chlordiazepoxide, estrogen Reduces the metabolism of drugs by Reduces the metabolism of drugs by

the cytochrome P450 pathway:the cytochrome P450 pathway: warfarinwarfarin

Reduces levels of fluvoxine, Reduces levels of fluvoxine, imipramine.imipramine.

Increases levels of clozapine.Increases levels of clozapine.Metz CN, et al. Med Clin N Amer 2004;1399-1413.

Other Medical Other Medical ProblemsProblems

Increases the risk of: Increases the risk of: Dementia & Alzheimer’s (X 2) and cognitive Dementia & Alzheimer’s (X 2) and cognitive

dysfunction (X 1.5).dysfunction (X 1.5). Insulin resistance and risk (X 1.45-1.94) and Insulin resistance and risk (X 1.45-1.94) and

severity of diabetes.severity of diabetes. Grave’s Disease and ophthalmopathy.Grave’s Disease and ophthalmopathy. Cataracts.Cataracts. Severity of rheumatoid arthritis.Severity of rheumatoid arthritis. Impotence (X 2.5).Impotence (X 2.5). Psoriasis.Psoriasis.

Sundaram R, et al. Med Clin N Amer 2004;1391-7. Mallamapalli A, et al. Med Clin N Amer 2004;1431-51. Sabia S, et al. Arch Intern Med 2008:168:1165-73.

Smokeless TobaccoSmokeless Tobacco

Snuff, chewing, or “spit” tobacco.Snuff, chewing, or “spit” tobacco. Used by 5 million adults and more Used by 5 million adults and more

than 750,000 adolescents.than 750,000 adolescents. Increases risk of oral cancer, dental Increases risk of oral cancer, dental

problems such as receding gums, problems such as receding gums, bone loss, and bad breath.bone loss, and bad breath.

Increased heart rate by 16 bpm, blood Increased heart rate by 16 bpm, blood pressure by 10 mm Hg, and pressure by 10 mm Hg, and epinephrine by 50% among 16 epinephrine by 50% among 16 healthy young men. healthy young men.

Wolk R. J Amer Coll Cardiol 2005;45:910-4.

Secondhand SmokeSecondhand Smoke

Secondhand smoke exposure is Secondhand smoke exposure is responsible for 38,000 deaths including responsible for 38,000 deaths including 3000 lung cancer deaths annually in the 3000 lung cancer deaths annually in the USUS11. .

Living with a smoker increases the risk of Living with a smoker increases the risk of ischemic heart disease death by 30-57%ischemic heart disease death by 30-57%3-5.3-5.

1. www.americanheart.org. 3. Bartecchi, C, et al. Circulation 2006;114:1490-6. 4. Taylor AE, et al. Circulation 1992;86:699-702. 5. Barnoya J, et al. Circulation 2005;111:2684-98.

Secondhand SmokeSecondhand Smoke May rapidly precipitate atherothrombotic May rapidly precipitate atherothrombotic

events.events. Increases CRP, fibrinogen, and ox-LDL similar Increases CRP, fibrinogen, and ox-LDL similar

in magnitude to smokers.in magnitude to smokers. Increases platelet aggregation, augments Increases platelet aggregation, augments

MMP activity, thus plaque destabilizationMMP activity, thus plaque destabilization Decreases HDL, causes mitochondrial damage, Decreases HDL, causes mitochondrial damage,

insulin resistance.insulin resistance. 30 minutes SHS impairs coronary endothelial 30 minutes SHS impairs coronary endothelial

function and increases aortic stiffness similar function and increases aortic stiffness similar to smokers.to smokers.

Reduces heart rate variability.Reduces heart rate variability.Barnoya J, et al. Circulation 2005;111;2684-98

Clean Indoor Air & Clean Indoor Air & Acute Coronary Acute Coronary

SyndromesSyndromes In Helena, MT, there was a 40% reduction in the In Helena, MT, there was a 40% reduction in the number of heart attacks with a clean indoor air policy, number of heart attacks with a clean indoor air policy, that returned to prior levels when it was overturned.that returned to prior levels when it was overturned.22

In Pueblo, CO, there was a 27% reduction in heart In Pueblo, CO, there was a 27% reduction in heart attacks over the 18-month period after a comprehensive attacks over the 18-month period after a comprehensive public Smoke-Free Air Act = a reduction by public Smoke-Free Air Act = a reduction by 70/100,000/year vs. no change in Colorado Springs 70/100,000/year vs. no change in Colorado Springs during the same period. during the same period. 33

In Scotland, in the year after smoke-free legislation in In Scotland, in the year after smoke-free legislation in March 2006 there was a 17% reduction in hospital March 2006 there was a 17% reduction in hospital admissions for acute coronary syndromes (95% CI 16-admissions for acute coronary syndromes (95% CI 16-18%) vs a 4% reduction in England. This was a 18%) vs a 4% reduction in England. This was a reduction of 14% among smokers, 19% among former reduction of 14% among smokers, 19% among former smokers, and 21% among never smokers.smokers, and 21% among never smokers.

1. Ritter J. USA Today March 9, 2005:7D. 2. Bartecchi, C, et al. Circulation 2006;114:1490-6. 3. Pell JP, et al. N Engl J Med 2008;359:482-91.

Secondhand SmokeSecondhand Smoke

Pre-school age children exposed to Pre-school age children exposed to their parents’ smoke are 20% more their parents’ smoke are 20% more likely to get middle ear infections.likely to get middle ear infections.

Maternal smoking ½ ppd increases Maternal smoking ½ ppd increases COPD risk 70% in their childrenCOPD risk 70% in their children22..

March 8, 2005 California Air March 8, 2005 California Air Resources Board links passive Resources Board links passive smoking to a 26-90% increased risk smoking to a 26-90% increased risk of breast cancerof breast cancer33..

2. Reichert VC, et al. Med Clin N Amer 2004;88:1467-81.3. Ritter J. USA Today March 9, 2005:7D.

States with States with Restrictions as of Restrictions as of

12/31/0712/31/07 Restrictions in private-sector Restrictions in private-sector

worksites in 37 (39) states.worksites in 37 (39) states. Restrictions in restaurants in 41, but Restrictions in restaurants in 41, but

not in: AL. Smoke-free in 21 states.not in: AL. Smoke-free in 21 states. Restrictions in bars in only 20. Restrictions in bars in only 20.

Smoke-free in 13 states.Smoke-free in 13 states. As of 2003, 77% of US workers in a As of 2003, 77% of US workers in a

smoke-free workplace.smoke-free workplace.

MMWR 2008 57(20):549-52.

American Cancer American Cancer Society Society Alabama Alabama

SurveySurveyOf 500 registered Alabama voters who participated:Of 500 registered Alabama voters who participated: 78% responded in favor of a law making all 78% responded in favor of a law making all

Alabama workplaces smoke-free. Alabama workplaces smoke-free. 95% viewed secondhand smoke as at least some 95% viewed secondhand smoke as at least some

kind of health hazard. kind of health hazard. 92% agreed no one should be exposed to 92% agreed no one should be exposed to

secondhand smoke in the workplace. secondhand smoke in the workplace. 79% responded that it is the government's 79% responded that it is the government's

responsibility to promote and protect public responsibility to promote and protect public health. health.

81% said they were likely to vote in the next 81% said they were likely to vote in the next election. election.

Performed by Little rock-based Opinion Research Associates January 2008

Coalition for a Coalition for a Tobacco-Free Tobacco-Free

AlabamaAlabama Alabama Academy of Family Physicians Alabama Academy of Family Physicians Alabama Citizens Action Program (ALCAP) Alabama Citizens Action Program (ALCAP) Alabama Department of Public Health Alabama Department of Public Health Alabama Faith United Against Tobacco Alabama Faith United Against Tobacco Alabama Sports Festival Alabama Sports Festival Alabama State Nurses Association Alabama State Nurses Association American Academy of Pediatrics - Alabama Chapter American Academy of Pediatrics - Alabama Chapter American Cancer Society American Cancer Society American College of Cardiology - Alabama Chapter American College of Cardiology - Alabama Chapter American Heart Association American Heart Association Alabama Lung Association Alabama Lung Association Blue Cross Blue Shield Blue Cross Blue Shield DuBois Institute DuBois Institute Medical Association for the State of Alabama Medical Association for the State of Alabama

Other ImpactsOther ImpactsPersonal ExpensePersonal Expense

Cigarettes- At $3.27/pack, 1ppd X 50 years Cigarettes- At $3.27/pack, 1ppd X 50 years will cost $59,677 in 2005 dollars. will cost $59,677 in 2005 dollars.

Duke economist Frank Sloan estimates at Duke economist Frank Sloan estimates at $40/pack or $220,000 for a 24YO man in $40/pack or $220,000 for a 24YO man in The The Price of SmokingPrice of Smoking.. Cost of cigarettes + excise taxes.Cost of cigarettes + excise taxes. Life and property insurance.Life and property insurance. Medical care for the smoker and his family.Medical care for the smoker and his family. Lost earnings due to acute illness and disability.Lost earnings due to acute illness and disability. Lost receipt from private pensions, social security Lost receipt from private pensions, social security

and Medicare due to early death.and Medicare due to early death. Reduced quality of life due to illness and disability.Reduced quality of life due to illness and disability. Lost retirement (life expectancy about 67 years). Lost retirement (life expectancy about 67 years).

WalMart April 5, 2005. Duke Magazine 2005;91:17. Sloan FA, et al. The Price ofSmoking 2004. The MIT Press, Cambridge, MA.

Other ImpactsOther ImpactsSocietal ExpenseSocietal Expense

$76 billion societal medical expense:$76 billion societal medical expense: $27 billion ambulatory$27 billion ambulatory $19 billion nursing home$19 billion nursing home $17 billion hospital$17 billion hospital $6.4 billion prescription drugs$6.4 billion prescription drugs $5.4 billion other$5.4 billion other

$98 billion in lost productivity costs $98 billion in lost productivity costs annually.annually.

$204 billion total cost.$204 billion total cost.

http://apps.nccd.cdc.gov/sammec/computations.asp

Smoking and Health-Smoking and Health-Related Quality of Related Quality of

Life in Old AgeLife in Old Age

1658 healthy white men in Helsinki 1658 healthy white men in Helsinki Businessman Study 40-55 YO enrolled 1974, Businessman Study 40-55 YO enrolled 1974, surveyed 2000surveyed 2000

Never smokers lived ten years longer, and Never smokers lived ten years longer, and their extra years were of better quality.their extra years were of better quality.

Health-related quality of Life (HRQoL) Health-related quality of Life (HRQoL) measured with Rand 36-Item Health Surveymeasured with Rand 36-Item Health Survey

Strandberg AY, et al. Arch Intern Med 2008: 168:1968-74

.

Strandberg, A. Y. et al. Arch Intern Med 2008;168:1968-1974.

The unadjusted association of smoking status and the number of cigarettes smoked daily at baseline in 1974 and mortality during the 26-year follow-up period

Strandberg, A. Y. et al. Arch Intern Med 2008;168:1968-1974.

The age-adjusted association of smoking status at baseline in 1974 and health-related quality of life as RAND 36-Item Health Survey (RAND-36) scores in 2000

Other Impacts - Other Impacts - SocialSocial

Hygiene and odor distasteful to othersHygiene and odor distasteful to others Wrinkles (X 2.3-4.7) and smokers’ nailsWrinkles (X 2.3-4.7) and smokers’ nails Loss of credibility with one’s children:Loss of credibility with one’s children:

““You’re doing something you know is bad for You’re doing something you know is bad for you!”you!”

Learned lack of self-control increases children’s Learned lack of self-control increases children’s chances of addiction to cigarettes and other chances of addiction to cigarettes and other substances as well as other behavior patterns.substances as well as other behavior patterns.

Prevalence of Prevalence of Smoking Smoking >> 18yo 18yoNational Health National Health Interview SurveyInterview Survey

45.3 million current smokers in the US

45.7 million former smokers

MMWR 2007;56(44)1157-61.

23.9%

20.8%

18.0%

Smoking in Smoking in AlabamaAlabama

The percentage of Alabamians who smoked The percentage of Alabamians who smoked has gone down from 30.6% in 1990 to has gone down from 30.6% in 1990 to 25.3% in 2002 to 23.2% in 2006.25.3% in 2002 to 23.2% in 2006.

We receive $100,000,000 a year from the We receive $100,000,000 a year from the $206 billion Master Settlement Agreement. $206 billion Master Settlement Agreement. Only a few hundred thousand dollars go to Only a few hundred thousand dollars go to tobacco prevention and cessation tobacco prevention and cessation programs.programs.

In 2005, national tobacco-industry In 2005, national tobacco-industry marketing expenditures were 13.1 billion marketing expenditures were 13.1 billion dollars.dollars.

Birmingham News November 23, 2004. MMWR 2007;56(44):1157-61.

Smoking and Smoking and ChildrenChildren

80% of adult smokers began before 80% of adult smokers began before age 18.age 18.

Every dayEvery day Nearly 4000 children under age 18 try Nearly 4000 children under age 18 try

their first cigarette.their first cigarette. 2000 children under age 18 become 2000 children under age 18 become

regular smokers. regular smokers.

American Heart Association 2005. CDC April 1, 2005. MMWR 2008;57(25):689-91.

Smoking Frequency Smoking Frequency Among High School Among High School

StudentsStudents

0

10

20

30

40

50

60

70

80

1991 1995 1999 2003 2007

EverCurrent 30 daysCurrent frequent

MMWR 2008;57(25):689-91.

-school-based tobacco-use prevention policies and procedures

-higher price + excise tax

-reduced parental and societal prevalence

-restricted advertising

-counter-advertising

-less in movies and videos

-smoke-free ordinances

-reduced availability

Cigarette Use - AgeCigarette Use - Age

0

5

10

15

20

25

30

35

40

45

50

1985 1999 2000 2001 2006

12-17yo18-25yo>25yo25-4445-64>65

The World Almanac 2003. MMWR 2007;56(44):1157-61.

Global Cigarette Global Cigarette ConsumptionConsumption

0

1000

2000

3000

4000

5000

6000

Annual Global Cigarette

Consumption (in billions)

1960 1970 1980 1990 2000

World Health Organization. http://www.who.int.tobacco/en/atlas8.pdf

This is 50 packs of cigarettes for every man, woman,and child on the planet!!

Worldwide Tobacco Worldwide Tobacco UseUse

1 billion male smokers and ¼ billion female 1 billion male smokers and ¼ billion female smokerssmokers11..

The The averageaverage Chinese man smokes 16 Chinese man smokes 16 cigarettes/day cigarettes/day 22..

In developed countries, 35% of men and In developed countries, 35% of men and 22% of women smoke; whereas in 22% of women smoke; whereas in developing countries, 58% of men and only developing countries, 58% of men and only 9% of women smoke9% of women smoke11..

4.83 million deaths attributed to smoking in 4.83 million deaths attributed to smoking in 2000200033. .

1. Mackay J and Eriksen MP. The Tobacco Atlas. Geneva:WHO;2002. 2. Knight E, et al. CRS Report for Congress; 1998. 3. Ezrati M and Lopez AD. Lancet 2003;362:847-52.

Benefits of QuittingBenefits of Quitting People who quit smoking before age 50 People who quit smoking before age 50

have half the risk of dying over the next 15 have half the risk of dying over the next 15 years of those who continue to smokeyears of those who continue to smoke11..

Within a year of quitting the excess risk of a Within a year of quitting the excess risk of a heart attack is reduced 80%.heart attack is reduced 80%.2. 2.

Within 2 wks of quitting platelet Within 2 wks of quitting platelet aggregation is reducedaggregation is reduced33. .

Smoking cessation improves pulmonary Smoking cessation improves pulmonary function 20-30% within 2 to 3 monthsfunction 20-30% within 2 to 3 months44..

Ten years after quitting the risk of lung Ten years after quitting the risk of lung cancer is reduced 50%cancer is reduced 50%4.4.

1. Ctrs for Dis Contr Prev. Morbid Mortal Wkly Rep 1990;39:2-10. 2. Wilhelmsson C, et al. Lancet 1975;1:415-20. 3. Morita H. Circulation 2005;45:589-94.

4. Jorenby DE. Circulation 2001;104:e51-2.

Smoking CessationSmoking Cessation

““Stopping smoking is easy. Stopping smoking is easy. I’ve done it a thousand I’ve done it a thousand times.”times.”

Mark Twain

Smoking CessationSmoking Cessation In 2000In 200011

68% of smokers wanted to quit (US and Europe)68% of smokers wanted to quit (US and Europe) 40% tried to quit40% tried to quit 5% succeeded in quitting5% succeeded in quitting

Personal Motivation is the most important factor as to Personal Motivation is the most important factor as to whether someone will quit smoking. Hospitalization, whether someone will quit smoking. Hospitalization, especially with a heart attack, is the most susceptible especially with a heart attack, is the most susceptible period that people have to be successful recipients of period that people have to be successful recipients of smoking cessation counseling.smoking cessation counseling.

After a heart attack 71% of people in an aggressive After a heart attack 71% of people in an aggressive smoking cessation program will quit smokingsmoking cessation program will quit smoking22..

In the Medicare database, those who received In the Medicare database, those who received smoking cessation counseling prior to discharge post-smoking cessation counseling prior to discharge post-MI were 20% more likely to survive 30 days, as well MI were 20% more likely to survive 30 days, as well as 60 days, and one yearas 60 days, and one year33..

1. American Heart Association. 2. Taylor CB, et al. Ann Intern Med 1990;113;118-23. 3. Houston TK. Am J Med 2005;118:269-75.

Medicare and SmokingMedicare and Smoking

9.3% of those over 65 smoke. 10% quit 9.3% of those over 65 smoke. 10% quit each year. each year.

Elderly account for 300,000 of the 440,000 Elderly account for 300,000 of the 440,000 deaths each year from smoking.deaths each year from smoking.

Smoking costs HHS 14.2 billion Smoking costs HHS 14.2 billion dollars/year, 10% of its total budget.dollars/year, 10% of its total budget.

1-800-QUIT-NOW and 1-800-QUIT-NOW and www.smokefree.govwww.smokefree.gov

Alabama Tobacco Alabama Tobacco QuitlineQuitline

1-800-QUITNOW1-800-QUITNOW Set up by CDC for any interested Alabamians.Set up by CDC for any interested Alabamians. Telephone counseling service.Telephone counseling service. Referral to local smoking cessation services.Referral to local smoking cessation services. Educational materials.Educational materials. Consultation for implementation and training Consultation for implementation and training

on the USPHS Clinical Practice Guidelines for on the USPHS Clinical Practice Guidelines for Treating Tobacco Use and Dependence.Treating Tobacco Use and Dependence.

Provide nicotine replacement therapy coupons.Provide nicotine replacement therapy coupons.

Alabama MD 2005;41:1-3.

Quitting SmokingQuitting Smoking

A recommendation by a health care A recommendation by a health care provider will increase chances of provider will increase chances of success by 30%.success by 30%.

Behavioral treatment increases Behavioral treatment increases chances of success by 50%.chances of success by 50%. Identification of and avoidance or Identification of and avoidance or

coping with smoking triggers.coping with smoking triggers. Social support by a clinician, family, Social support by a clinician, family,

friends, co-workers.friends, co-workers.Zbikowski SM, et al. Med Clin N Amer 2004;88:1453-65.

Public Health Public Health Service Guidelines – Service Guidelines –

The 5A ModelThe 5A Model1.1. AAsk about smoking- every patient every visit.sk about smoking- every patient every visit.2.2. AAdvise one to quit- in a clear, strong dvise one to quit- in a clear, strong

personalized manner.personalized manner.3.3. AAssess willingness to quit.ssess willingness to quit.4.4. AAssist those willing to quit.ssist those willing to quit.

1.1. If willing, offer medication, and provide or refer for If willing, offer medication, and provide or refer for counseling or additional treatment. (1-800-counseling or additional treatment. (1-800-QUITNOW.)QUITNOW.)

2.2. If unwilling, provide interventions designed to If unwilling, provide interventions designed to increase future quit attempts.increase future quit attempts.

5.5. AArrange for follow-up- if willing, at a week rrange for follow-up- if willing, at a week and a month. If unwilling, address again at and a month. If unwilling, address again at next visit.next visit.

Fiore MC, et al. Treating tobacco use and dependence: clinical practice guideline.Rockville (MD): US Dept Health Human Svcs Public Health Svc; 2008 Update.

Assist those willing to Assist those willing to quit.quit.

Set a quit date, ideally within two weeks. Tell family, friends, and co-workers about

quitting, and request understanding and support.

Anticipate challenges such as nicotine withdrawal, particularly during the first few critical weeks.

Remove tobacco products from your environment. Prior to quitting, avoid smoking in places where you spend a lot of time such as home, work, car. Make your home smoke-free.

Recommend the use of medications to reduce withdrawal symptoms.

Fiore MC, et al. Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Treating Tobacco Use and Dependence: 2008 Update.Update. Clinical Practice Guideline. Rockville, MD: Clinical Practice Guideline. Rockville, MD: USDHHS. PHS. May 2008.USDHHS. PHS. May 2008.

Assist those willing to Assist those willing to quit.quit.

Total abstinence. Past quit experience. Anticipate triggers/ alter routines:

alcohol, morning cup of coffee, weekly poker game.

Other smokers in the household. Provide a supportive clinical environment. Provide other sources of help.

1-800-QUIT-NOW, www.smokefree.gov, Fiore MC, et al. Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Treating Tobacco Use and Dependence: 2008

Update.Update. Clinical Practice Guideline. Rockville, MD: Clinical Practice Guideline. Rockville, MD: USDHHS. PHS. May 2008.USDHHS. PHS. May 2008.

Quitting and Quitting and MedicationsMedications

Nicotine supplements – gum, patches, lozenges, Nicotine supplements – gum, patches, lozenges, inhalers, nasal sprayinhalers, nasal spray

Anti-depressantsAnti-depressants Buproprion SR (Wellbutrin SR or Zyban)Buproprion SR (Wellbutrin SR or Zyban) Nortryptilline and clonidine (not approved for this Nortryptilline and clonidine (not approved for this

use, listed as second-line in the guidelines)use, listed as second-line in the guidelines) Varenicline (Chantix) -nicotine-receptor partial Varenicline (Chantix) -nicotine-receptor partial

agonistagonist Rimonabant (not available) –cannabanoid Rimonabant (not available) –cannabanoid

receptor blockerreceptor blocker NicVax* and Ta-Nic* trigger the production of NicVax* and Ta-Nic* trigger the production of

antibodies that bind to nicotine molecules and antibodies that bind to nicotine molecules and prevent them from reacting with receptors in prevent them from reacting with receptors in the brain.the brain.

Should all be used in combination with Should all be used in combination with counselingcounseling*Currently in clinical trials

Transdermal Transdermal Nicotine + Nicotine +

Nortryptiline vs Nortryptiline vs Placebo Placebo

0

10

20

30

40

50

60

70

QD 30 60 90 120 150 180

Days since Quit Date

% Q

uit Nicotine +

Nortryptiline 75 mgNicotine + Placebo

18/79 (23%) vs 8/79(10%); p=0.052

Nicotine

Nortryptiline

Prochazka A, et al. Arch Intern Med 2004;164:2229-33.

Clonidine also Clonidine also listed as second-listed as second-line treatment in line treatment in the guidelines.the guidelines.

Buproprion SR Buproprion SR 12-Month Abstinence 12-Month Abstinence

RateRate

PlaceboN=160

Nicotine Replacement

N=244

Buproprion

N=244

Buproprion+ NRTN=245

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

Jorenby DE, et al: NEnglJMed 1999;340:685-91.

p<.001

p<.001

150 mg po qd X 3 days, then 150 mg po bid.150 mg po qd X 3 days, then 150 mg po bid.

Varenicline - Varenicline - ChantixChantix

After inhalation, nicotine predominantly binds to the After inhalation, nicotine predominantly binds to the nicotinic aceylcholine (nACh) receptors located in the nicotinic aceylcholine (nACh) receptors located in the mesolimbic-dopamine system of the brain within a mesolimbic-dopamine system of the brain within a matter of seconds. Nicotine specifically activates matter of seconds. Nicotine specifically activates 44ββ2 nicotinic receptors in the Ventral Tegmental 2 nicotinic receptors in the Ventral Tegmental Area (VTA) causing an immediate dopamine release Area (VTA) causing an immediate dopamine release at the Nucleus Accumbensat the Nucleus Accumbens11 (nAcc). The dopamine (nAcc). The dopamine release is believed to be a key component of the release is believed to be a key component of the reward circuitry associated with cigarette smokingreward circuitry associated with cigarette smoking11..

Varenicline is a selective α4β2 nicotinic receptor Varenicline is a selective α4β2 nicotinic receptor partial agonist.partial agonist.

Reduces the rewarding and reinforcing effects of Reduces the rewarding and reinforcing effects of nicotine.nicotine.

Picciotto MR, et al. Nicotine Tob Res. 1999; Suppl 2:S121-125.

Varenicline vs Varenicline vs PlaceboPlacebo

VareniclineVarenicline PlaceboPlacebo

Adverse Adverse EffectEffect

% of subjects% of subjects

NauseaNausea 35.835.8 11.211.2

InsomniaInsomnia 22.022.0 12.712.7

Abnormal Abnormal dreamsdreams

14.414.4 5.05.0

HeadacheHeadache 16.816.8 14.314.3

Other GI Other GI effects*effects*

22.522.5 11.811.8

Stop due to Stop due to AEAE

12.012.0 8.18.1Hays JT, and Ebbert JO. Hays JT, and Ebbert JO. N Engl J Med N Engl J Med 2008:359:2018-242008:359:2018-24..*vomiting, constipation, diarrhea, flatulence, dyspepsia.*vomiting, constipation, diarrhea, flatulence, dyspepsia.

VareniclineVarenicline

Essentially no metabolism, 80% excreted Essentially no metabolism, 80% excreted unchanged in urine.unchanged in urine.

No meaningful drug-drug interactions.No meaningful drug-drug interactions. Start at 0.5 mg/day for 3 days, 0.5 bid for 4 Start at 0.5 mg/day for 3 days, 0.5 bid for 4

days, then 1.0 mg bid for 3-6 months.days, then 1.0 mg bid for 3-6 months. Can reduce dosage to 1.0 mg daily for nausea.Can reduce dosage to 1.0 mg daily for nausea. Can reduce to 0.5 mg daily for Cr Clearance Can reduce to 0.5 mg daily for Cr Clearance

< 30 cc per min or dialysis patients. Removed < 30 cc per min or dialysis patients. Removed with dialysis.with dialysis.

Use with GETQUIT Support Program, 1-800-Use with GETQUIT Support Program, 1-800-QUIT-NOW, www.smokefree.gov.QUIT-NOW, www.smokefree.gov.

Hays JT, and Ebbert JO. Hays JT, and Ebbert JO. N Engl J Med N Engl J Med 2008:359:2018-24.2008:359:2018-24.

Assist those unwilling Assist those unwilling to quit.to quit.

Motivational Motivational InterviewingInterviewing1. Express empathy.

2. Develop discrepancy. 3. Roll with resistance.4. Support self-efficacy.


Assist those unwilling Assist those unwilling to quit.to quit.

Enhancing motivation Enhancing motivation to quit- The 5 R’sto quit- The 5 R’s1. Relevance-personalize to disease states, family

situation.2. Risks-

1. Acute- SOB, asthma flares, sinusitis, ulcers, pregnancy.2. Long-term- MI, CVA, COPD, cancer.3. Environmental- spouse, infants, children.

3. Rewards- health, taste, smell, money, self-image, impact on children’s habits, health of family, SOB, nails, teeth, wrinkles, quality of life, life expectancy, retirement.

4. Roadblocks- withdrawal, “reduced stress” myth, fear of failure, weight gain, lack of support- do for yourself.

5. Repetition every visit- most people make repeated quit attempts.


Arrange follow-up.Arrange follow-up.

Contact within the first week, and again within the first month, then as needed.

Identify problems encountered, and anticipate challenges in the future. Assess medication use and problems. Remind of Quitline/support.

Congratulate them on their successes, and encourage complete abstinence.

Continue to assess use at every visit, and provide feedback.


SummarySummary Smoking is far and away the most important Smoking is far and away the most important

behavior affecting life expectancy and long-behavior affecting life expectancy and long-term health of smokers. term health of smokers. 64% die as a result.64% die as a result.

Educate and Motivate your patient: Educate and Motivate your patient: “If you “If you smoke, carefully consider what reasons you use smoke, carefully consider what reasons you use to commit yourself to continuing to smoke, and to commit yourself to continuing to smoke, and what factors about your health and future what factors about your health and future relationships might motivate you to quit.”relationships might motivate you to quit.”

““You can quit! I would love to assist you!”You can quit! I would love to assist you!” Use the 5 A’s, medications, and other Use the 5 A’s, medications, and other

resources.resources.

ConclusionConclusion

““Sparing a few minutes for Sparing a few minutes for tobacco cessation: if only half of tobacco cessation: if only half of all nurses helped one patient per all nurses helped one patient per month quit smoking, more than month quit smoking, more than 12 million smokers would 12 million smokers would overcome their addictions every overcome their addictions every year.”year.”

Bialous SA, Sarna L.Bialous SA, Sarna L. Am J NursAm J Nurs. . 2004;104(12):54-60.2004;104(12):54-60.

AtherosclerosisAtherosclerosis

A process that builds up plaque A process that builds up plaque inside the walls of arteries or blood inside the walls of arteries or blood vessels that carry blood to the vessels that carry blood to the organs of the body.organs of the body. May reduce the blood flow to these May reduce the blood flow to these

organs gradually.organs gradually. May form blood clots which rapidly May form blood clots which rapidly

reduce blood flow.reduce blood flow. May cause spasm in these arteries. May cause spasm in these arteries.

AtherosclerosisAtherosclerosisMajor Organs Major Organs

AffectedAffected Heart - coronary artery diseaseHeart - coronary artery disease

Angina or chest discomfort, shortness of Angina or chest discomfort, shortness of breathbreath

Myocardial infarctionMyocardial infarction Congestive heart failureCongestive heart failure Arrhythmias and sudden deathArrhythmias and sudden death

Brain – cerebrovascular diseaseBrain – cerebrovascular disease Stroke and transient ischemic attackStroke and transient ischemic attack

Peripheral vascular diseasePeripheral vascular disease Claudication, skin ulcers, wound healing, Claudication, skin ulcers, wound healing,

gangrene, aneurysmsgangrene, aneurysms

AtherosclerosisAtherosclerosisRisk FactorsRisk Factors

Factors that increase the risk and Factors that increase the risk and severity of atherosclerosis:severity of atherosclerosis:

Modifiable and un-modifiableModifiable and un-modifiable

Cigarette Use By Cigarette Use By GenderGender

0

10

20

30

40

50

60

1965 1970 1975 1980 1985 1990 1995 2000 2003

MaleFemale

http://www.cdc.gov/nchs.

45.4 million smokers in the US.

Cigarette Use - Cigarette Use - EducationEducation

0

5

10

15

20

25

30

35

40

45

1985 1999 2000 2001 2006

Non-high school gradsHigh school gradsSome collegeCollege grads

MMWR 2007;56(44):1157-61.

NicotineNicotine Pleasurable effects:Pleasurable effects:

ArousalArousal Relief of anxietyRelief of anxiety

Nicotine withdrawal:Nicotine withdrawal: Irritability, frustration, angerIrritability, frustration, anger Dysphoric or depressed moodDysphoric or depressed mood AnxietyAnxiety Difficulty concentratingDifficulty concentrating RestlessnessRestlessness Increased appetite or weight gainIncreased appetite or weight gain Decreased heart rateDecreased heart rate InsomniaInsomnia

DSM-IVDSM-IV. Washington, DC.:American Psychiatric Association. 1994. Washington, DC.:American Psychiatric Association. 1994..

Nicotine Nicotine pharmacokineticspharmacokinetics

Rapid absorption from smoke due to large Rapid absorption from smoke due to large pulmonary capillary surface areapulmonary capillary surface area

Rapid transit directly to the brain undilutedRapid transit directly to the brain undiluted Immediate rapid rise in nicotine levelsImmediate rapid rise in nicotine levels Binding and conformational change in Binding and conformational change in

pentameric nicotinic acetylcholine pentameric nicotinic acetylcholine receptors inreceptors in Nucleus accumbensNucleus accumbens Mesolimbic system-reward center of the brain- Mesolimbic system-reward center of the brain-

highest concentrations of high affinity highest concentrations of high affinity 4422 Ventral tegmental area Ventral tegmental area

Henningfield JE, et al. Henningfield JE, et al. Drug Alcohol DependDrug Alcohol Depend 1993:33:23-9. Watkins SS, et 1993:33:23-9. Watkins SS, et al. Nicotine al. Nicotine Tob ResTob Res 2000:2:19-37. 2000:2:19-37.

Hays J and Ebbert J. N Engl J Med 2008;359:2018-2024

The Actions of Nicotine and Varenicline in the Brain

Varenicline - Varenicline - ChantixChantix

A selective α4β2 nicotinic receptor A selective α4β2 nicotinic receptor partial agonist developed by Pfizer.partial agonist developed by Pfizer.

Reduces the rewarding and Reduces the rewarding and reinforcing effects of nicotine.reinforcing effects of nicotine.

A randomized placebo-controlled A randomized placebo-controlled trial of Varenicline 0.5 mg bid trial of Varenicline 0.5 mg bid (N=253) vs Varenicline 1.0 mg bid (N=253) vs Varenicline 1.0 mg bid (N=253) vs Placebo (N=121)(N=253) vs Placebo (N=121)

Oncken C. American College of Cardiology Meeting, March 8, 2005.

Varenicline - Quit Varenicline - Quit Rate Rate

11.6 12.4

37.2

45.140.7

50.6

0

10

20

30

40

50

60

Weeks 4-7 Weeks 9-12

Qui

t Rat

e (%

) Placebo

Varenicline 0.5 mg bid(N=253)Varenicline 1.0 mg bid(N=253)

All values p <0.0001vs placebo

Oncken C. American College of Cardiology Meeting, March 8, 2005.

Treating Tobacco Use Treating Tobacco Use and Dependence: and Dependence:

2008 Update2008 Update Tobacco use presents a rare confluence of Tobacco use presents a rare confluence of

circumstances:circumstances: A highly significant health threat;A highly significant health threat; A disinclination among clinicians to intervene A disinclination among clinicians to intervene

consistently;consistently; The presence of effective interventions.The presence of effective interventions.

Indeed it is difficult to identify any other Indeed it is difficult to identify any other condition that presents such a mix of condition that presents such a mix of lethality, prevalence, and neglect, despite lethality, prevalence, and neglect, despite effective and readily available effective and readily available interventions.interventions.

Fiore MC, et al. Fiore MC, et al. Treating Tobacco Use and Treating Tobacco Use and Dependence: 2008 Update.Dependence: 2008 Update. Clinical Practice Guideline. Clinical Practice Guideline. Rockville, MD: USDHHS. PHS. May 2008. Rockville, MD: USDHHS. PHS. May 2008.

Why should a busy clinician Why should a busy clinician consider making treatment of consider making treatment of tobacco use a priority?tobacco use a priority?

1.1. Clinicians make a difference with even a Clinicians make a difference with even a minimal (<3 minute) intervention.minimal (<3 minute) intervention.

2.2. A relation exists between the intensity of A relation exists between the intensity of intervention and tobacco cessation outcome.intervention and tobacco cessation outcome.

3.3. Even when patients are not willing to make a Even when patients are not willing to make a quit attempt at this time, clinician-delivered quit attempt at this time, clinician-delivered brief interventions enhance motivation and brief interventions enhance motivation and increase the likelihood of future quit attempts.increase the likelihood of future quit attempts.

4.4. Tobacco users are being primed to consider Tobacco users are being primed to consider quitting by a wide range of societal and quitting by a wide range of societal and environmental factors (e.g., public health environmental factors (e.g., public health messages, family members).messages, family members).Fiore MC, et al. Fiore MC, et al. Treating Tobacco Use and Dependence: 2008 Treating Tobacco Use and Dependence: 2008

Update.Update. Clinical Practice Guideline. Rockville, MD: Clinical Practice Guideline. Rockville, MD:

USDHHS. PHS. May 2008USDHHS. PHS. May 2008..

Why should a busy clinician Why should a busy clinician consider making treatment of consider making treatment of tobacco use a priority?tobacco use a priority?

5.5. There is growing evidence that smokers who There is growing evidence that smokers who receive clinician advice and assistance with receive clinician advice and assistance with quitting report greater satisfaction with their quitting report greater satisfaction with their health care than those who do not.health care than those who do not.

6.6. Tobacco use interventions are highly cost-Tobacco use interventions are highly cost-effective.effective.

7.7. Tobacco use has a high case fatality rate Tobacco use has a high case fatality rate (>50% of long-term smokers will die of (>50% of long-term smokers will die of smoking related disease.smoking related disease.


Abstinence Rates by # Treatment Abstinence Rates by # Treatment SessionsSessions

Meta-analysis 46 studiesMeta-analysis 46 studiesNumber of Number of SessionsSessions

NumbeNumber of r of armsarms

Estimated Odds Estimated Odds Ratio (95% CI)Ratio (95% CI)

Estimated Estimated Abstinence Rate Abstinence Rate (95% CI)(95% CI)

0-1 session0-1 session 4343 1.01.0 12.412.4

2-3 sessions2-3 sessions 1717 1.4 (1.1-1.7)1.4 (1.1-1.7) 16.3 (13.7-19.0)16.3 (13.7-19.0)

4-8 sessions4-8 sessions 2323 1.9 (1.6-22)1.9 (1.6-22) 20.9 (18.1-23.6)20.9 (18.1-23.6)

>8 sessions>8 sessions 5151 2.3 (2.1-3.0)2.3 (2.1-3.0) 24.7 (21.0-28.4)24.7 (21.0-28.4)


Secondary Prevention and Long Term Secondary Prevention and Long Term ManagementManagement

•Status of tobacco use should be asked at every visit.

•Every tobacco user and family member who smoke should be advised to quit at every visit.

•The tobacco user’s willingness to quit should be assessed.

•The tobacco user should be assisted by counseling and developing a plan for quitting.

•Follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and pharmacological rx) should be arranged.

•Exposure to environmental tobacco smoke at home and work should be avoided.

Smoking 2007 Goal: Complete cessation. No exposure to environmental tobacco smoke.

Goals Class I Recommendations

NEW

NEW

Prolonged AbstinenceProlonged AbstinencePlacebo

Rimonabant 5mg

Rimonabant 20mg

N=261 N=261N=262 N=189 N=183 N=188

16.1

20.6

15.6

20.2

27.6

36.2

0

5

10

15

20

25

30

35

40

ITT Completers

PercentAbstinent

(%)p=0.004

p=0.002

OR=2.0 - 95%CI=[1.296;3.046]

OR=2.2 - 95%CI=[1.374;3.456]

STRATUS-US Study. American College of Cardiology Meeting, March 2004.

Camel late 1940s

Brandt, AM. N Engl J Med 2008;359;445-8.

““Reports of serious Reports of serious drug reactions hit drug reactions hit

record”record” The FDA should forcefully warn patients taking Chantix that they may The FDA should forcefully warn patients taking Chantix that they may

have blackouts and other problems that could lead to accidents, the have blackouts and other problems that could lead to accidents, the report said. The current warnings say that patients may be too impaired report said. The current warnings say that patients may be too impaired to drive or operate heavy machinery, but such language is standard for to drive or operate heavy machinery, but such language is standard for many medications.many medications.

The report found 15 cases of Chantix patients who appeared to have The report found 15 cases of Chantix patients who appeared to have been involved in traffic accidents, and 52 additional cases involving been involved in traffic accidents, and 52 additional cases involving blackouts or loss of consciousness. The FDA received 1,001 reports of blackouts or loss of consciousness. The FDA received 1,001 reports of serious injuries possibly linked to Chantix, more than for the ten best-serious injuries possibly linked to Chantix, more than for the ten best-selling brand name drugs combined.selling brand name drugs combined.

Chantix "continued to provide a striking signal of safety issues that Chantix "continued to provide a striking signal of safety issues that require investigation and action," the report said. The authors require investigation and action," the report said. The authors acknowledged Pfizer's concern that publicity may be driving up the acknowledged Pfizer's concern that publicity may be driving up the number of reports, but nonetheless concluded that there are enough to number of reports, but nonetheless concluded that there are enough to warrant further action by the FDA.warrant further action by the FDA.

Pfizer said the total sum of its data on Chantix, including results from Pfizer said the total sum of its data on Chantix, including results from clinical trials, show that the drug's benefits clearly outweigh its risks.clinical trials, show that the drug's benefits clearly outweigh its risks.

"We stand by the efficacy and safety profile of Chantix," the company "We stand by the efficacy and safety profile of Chantix," the company said in a statement. "There are few things that provide greater health said in a statement. "There are few things that provide greater health benefits than quitting smoking. Pfizer is committed to reducing the benefits than quitting smoking. Pfizer is committed to reducing the prevalence of smoking globally. As part of that mission, we want to prevalence of smoking globally. As part of that mission, we want to increase peoples' understanding of the dangers of smoking and the increase peoples' understanding of the dangers of smoking and the benefits of quitting." benefits of quitting." Alonso-Zaldivar R. Alonso-Zaldivar R. The Boston Globe.The Boston Globe. 10/22/08 10/22/08

Restrictions on use of Restrictions on use of VareniclineVarenicline

Monitor patients closely if adverse Monitor patients closely if adverse behavioral effects are noted by patient behavioral effects are noted by patient or family. Report if suspected.or family. Report if suspected.

Package insert: safety concerns wile Package insert: safety concerns wile operating heavy machinery.operating heavy machinery.

FAA: pilots and air-traffic controllers FAA: pilots and air-traffic controllers may not use varenicline.may not use varenicline.

..also by the organization overseeing ..also by the organization overseeing interstate commercial truck and bus interstate commercial truck and bus drivers.drivers.

Hays JT, and Ebbert JO. Hays JT, and Ebbert JO. N Engl J Med N Engl J Med 2008:359:2018-242008:359:2018-24

States with States with Restrictions as of Restrictions as of

12/31/0712/31/07 Restrictions in private-sector worksites in Restrictions in private-sector worksites in

37, but not in: AK, IN, KS, KY, (MD), (MI), 37, but not in: AK, IN, KS, KY, (MD), (MI), MS, NC, SC, TX, VA, WV, WY.MS, NC, SC, TX, VA, WV, WY.

Restrictions in restaurants in 41, but not Restrictions in restaurants in 41, but not in: AL, IN, KY, MS, NC, SC, TX, WV, WY. in: AL, IN, KY, MS, NC, SC, TX, WV, WY. Smoke-free in 21 states.Smoke-free in 21 states.

Restrictions in bars in only 20. Smoke-Restrictions in bars in only 20. Smoke-free in 13 states.free in 13 states.

As of 2003, 77% of US workers in a As of 2003, 77% of US workers in a smoke-free workplace.smoke-free workplace.

MMWR 2008 57(20):549-52.

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