Tobacco In North Dakota

Eric L. Johnson, M.D.

Assistant Professor

Department of Family and Community Medicine

University of North Dakota

School of Medicine and Health Sciences

Physician Consultant North Dakota Tobacco Quitline/Quitnet

Assistant Medical Director

Altru Diabetes Center

Objectives

• Review Tobacco Related Disease in the U.S. and in North Dakota

• Understand Negative Health Effects of Second Hand (Passive) Smoke

• Review Negative Economic Impact of Tobacco

• Review High Quality Tobacco Cessation Resources in North Dakota

Tobacco Use in North Dakota

• ~20% of U.S. Adults smoke (41% in 1965)

• ~18% of ND adults smoke (~21% when Quitline launched 2004)

• 41% of ND Native Americans smoke

• 18% of Pregnant women in ND smoke vs. 12% in the U.S.

CDCND Dept of Health

Tobacco Use in North Dakota

• ~116,000 ND adults and ~8,000* HS students smoke cigarettes

• ~20,000 ND adults and ~3,800^ HS students use spit tobacco

(BRFSS 2008)(BRFSS 2008)

(YRBS 2005,2007)(YRBS 2005,2007)

North Dakota Department of HealthDivision of Tobacco Prevention and Control

North Dakota Department of HealthDivision of Tobacco Prevention and Control

Tobacco Use in North Dakota

• Native American population: 49.3% adults use tobacco (highest smoking rate of any ethnic group in U.S.)

• Smoking in pregnancy higher in North Dakota than national average: 18% vs. 12%

• WIC Clinic population survey: 45% smoked prior to pregnancy vs. 16% non-WIC

Tobacco’s Health Cost inNorth Dakota

• Smoking-attributable direct medical expenditures:

$250,000,000• Smoking-attributable productivity costs:

$192,000,000• Medicaid expenditures for smoking-related illnesses and

diseases:

$47,000,000

Annual Costs! CDC. Smoking-Attributable Mortality, Morbidity and Economic Costs (SAMMEC) report, 2008. CDC Data Highlights, 2006.

North Dakota spends $691 per capita on direct

medical expenditures and

lost productivity due to smoking

Tobacco Use in North Dakota

• Heart Disease and Cancer are the leading causes of death in North Dakota

• Tobacco use is the leading preventable cause of death

Smoking Causes Death

Smoking causes approximately• 90% of all lung cancer deaths in men• 80% of all lung cancer deaths in women• 90% of deaths from chronic obstructive lung

disease (COPD)

CDC

Smoking Causes DeathCompared with nonsmokers smoking increases

risk of—• Coronary heart disease by 2 to 4 times• Stroke by 2 to 4 times• Men developing lung cancer by 23 times• Women developing lung cancer by 13 times• Dying from chronic obstructive lung diseases (COPD) by

12 to 13 times• Also associated with risk of type 2 diabetes

CDC

Secondhand Smoke(Passive Smoking)

• Negative effects of smoke on people who aren’t doing the smoking

• No longer speculation that this is dangerous for those exposed to secondhand smoke

Secondhand Smoke DeathsUnited States• Lung cancer – 3,000 deaths annually • Heart Disease – 35,000 deaths annually

North Dakota• 80-140 deaths annually

CDCAmerican Cancer Society

Second Hand Smoke and Cardiovascular Risk (Heart Attack)• Cardiovascular Risk (Heart Attack) is

~80-90% of primary smoking

• Secondhand smoke increases risk of heart attack by 30%

• Well understood phenomenon- no longer speculative concerning harmful effects

Barnoya A, Glantz S Circulation May 24 2005The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General 2006

“Smoking Ban”

• “Smoking Ban” is not an appropriate description

More descriptive….

• “Comprehensive Smoke Free” legislation

• “Smoke Free” Policy

Smoke Free Legislation• Typically, legislation that eliminates smoking in public

places• The smoker is NOT the medical focus of this type of

legislation

(not protecting the smoker from themselves)• Focus in on reducing injury inflicted on others• Business impact (negative) is little or none (recent

Fargo area survey, others)

Smoke Free Legislation and Heart Attack

Location PopulationChange in Heart Attack

Hospital Admissions

 Helena 68,140 −40%

 Pueblo 698,229 (2counties) −41%

 New York 18,976,457 −8%

 Indiana 239,332 −50%

 Ohio 29,636 −20%

 Saskatoon 202,340 −13%

Communities Similar to Grand Forks

• Pueblo, CO

• Population 103,648

• College Town

• Decrease in Heart Attacks following “smoking ban” 27%

Communities Similar to Grand Forks

• Bowling Green, OH

• Population 29,636

• College Town

• Reduction in Heart Attacks following “smoking ban” 19%

Communities Similar to Grand Forks

• Helena, MT• Population 47,154 • College Town• Reduction in Heart Attack with “smoking

free” legislation 40%• Increase in Heart Attacks following smoke

free legislation repeal 40%

“Smoke Free Legislation” and Heart Attack

• 11 legitimate studies

• Europe, U.S., Canada

• Approx 17% reduction in Heart Attack across all studies

• Approx 195,000 Heart Attacks would be avoided in U.S. annually

• In an age of health care cost containment, can’t disregard

Long Term Tobacco Control

• California has longest running law in U.S.

• Reduction in adult smoking 40% 1998-2006

• Reduction in lung cancer 4 times faster than rest of U.S.

• Maine, New York, Washington 45-60% reduction in youth smoking

CDC MMWR 9-10-10

Tobacco Cessation

Nicotine is addictive…and this is precisely why it is there

• The cigarette is a highly engineered nicotine delivery device

• Chemicals like ammonia are added to release more nicotine

• Nicotine is there on purpose, for a purpose

• Nicotine is not a carcinogen (patients may not know this)

Pharmacotherapy(Medications)

For Tobacco Cessation

Pharmacotherapy(Medications)

• Nicotine replacement therapy (NRT)– Gum– Patch– Spray– Inhaler– Lozenge

• Bupropion (Zyban, Wellbutrin) • Varenicline (Chantix)• All are considered 1st line treatment

Medications typically will give better results when combined with

counseling

USPHS Guidelines 2008

Effective, High Quality Counseling Exists to

Assist in Quitting Tobacco in North

Dakota-NO cost to user to

access

Tobacco Quitlines

Web Based Cessation• Both are individualized, population-based, clinically

effective• Quitlines are specifically endorsed by U.S. Public Health

Service for Tobacco Cessation

North Dakota Tobacco Quitline

North Dakota Quitnet

• Free to all North Dakota residents• Up to 5 telephone counseling sessions• Counselors are in North Dakota at UND• FREE Nicotine replacement therapy (gum, patches) for

qualifying

• 7-month quit rate 34%*

• 13-month quit rate 33%*

• 3-5% quit rate with no support

*June 2010

nd.quitnet.com

Free to all North Dakota Residents

North Dakota Tobacco Quitline

• Launched Sept. 2004

• Large roll-out to ND providers- ~1800 providers received face to face or teleconference CME information from UND (Dr. Johnson and Dr. Anel)

• Continues to have excellent acceptance by North Dakota Providers

Client Satisfaction

North Dakota Tobacco Cessation• North Dakota Has High Quality, well respected

Options• Quitline: Thousands of Clients since 2004• Quitnet: Good roll-out since Feb. 2010 ~ 670

registered users through 9/5/10• These 2 services are integrated- ease of use• These programs have high acceptance by North

Dakota Providers and clients

Other Tobacco Control Incentives

• Several studies in the U.S. and Europe have shown that increasing tobacco taxes tend to drive down smoking rates

• California has shown that every $1 spent on tobacco control has saved $50 in their health care system-net savings is $80-$100 billion over 20 years

Tob Control - 01-APR-2010; 19 Suppl 1: i68-76Health Policy. 2007 Jul;82(2):142-52PLoS Med - 26-AUG-2008; 5(8): e178

Summary• Tobacco Related diseases have significant

impact on overall morbidity and mortality in North Dakota and the U.S.

• Tobacco Cessation has a positive impact on many disease states and is cost effective

• Tobacco Use is a Habit and an Addiction• Effective telephone based counseling and/or

web-based counseling is an effective tool in Tobacco Cessation

Acknowledgements• North Dakota State Department of Health,

Division of Tobacco Prevention and Control• University of North Dakota School of Medicine

and Health Sciences Department of Family and Community Medicine

• Mayo Clinic Tobacco Quitline• Dr. Donna A. Anel• Healthways Inc.