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Tobacco Cessation: Academic Partnerships for Success

Janie Heath PhD, APRN-BC, ANP, ACNP Associate Dean Academic Nursing Practice Medical College of Georgia

Respiratory Therapy

Objectives

Identify the importance of integrating tobacco cessation in DAILY practice Identify key strategies / approaches for integrating tobacco cessation in DAILY practice Identify essential resources for integrating tobacco cessation in DAILY practice
VISIT: www.tobaccofreenurses.org

TRENDS in ADULT SMOKING, by SEXU.S., 19552004


Trends in cigarette current smoking among persons aged 18 or older
60 50 40

Male

20.9% of adults are current smokers


23.4% 18.5%

Percent

30 20 10 0
1955 1959 1963 1967 1971 1975 1979 1983 1987 1991 1995 1999 2003

Female

44.5 Million Adults are Addicted to Cigarettes

Year

The BAD News: < 36% News: Receive 70% Information The GOOD want on to HOW quit to quit
Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 19652001 NHIS. Estimates since 1992 include some-day smoking.

STATE-SPECIFIC PREVALENCE of SMOKING among ADULTS, 2004


California 14.8% Kentucky 27.6%

Nevada 23.2% Utah 10.5% GA 23.3%


Centers for Disease Control and Prevention. (2005). MMWR 54:11241127.

STATE-Cigarette Excise Tax / Pk, 10/2006


California
87 cents

Kentucky
30 cents

HIGHEST

Nevada
80 cents

NJ = $2.56 LOWEST SC = 00.07cents

Utah
69.5 cents

GA
37 cents
Campaign for Tobacco-Free Kids. (2006). State Cigarette Excise Tax Rates & Rankings. Retrieved

PREVALENCE of ADULT SMOKING, by RACE/ETHNICITYU.S., 2004


33.4% American Indian/Alaska Native 22.2% White, non-Hispanic 20.2% Black, non-Hispanic 15.0% Hispanic 11.3% Asian
0% 10% 20% 30% 40% 50%

Centers for Disease Control and Prevention. (2005). MMWR 54:11211124.

Prevalence and Harm of SMOKING during PREGNANCY

Miscarriage Stillbirth Preterm delivery Low birth weight

BABY ALERT: 27% OF Tobacco Dependent WOMEN Continue to SMOKE THROUGHOUT PREGNANCY

PREVALENCE of ADULT SMOKING, by EDUCATIONU.S., 2004


26.2% No high school diploma 39.6% GED diploma 24.0% High school graduate 22.2% Some college 11.7% Undergraduate degree 8.0% Graduate degree
0% 10% 20% 30% 40% 50%

Centers for Disease Control and Prevention. (2005). MMWR 54:11211124.

Annual Causes of Death from Smoking Compared to Other PREVENTABLE Causes


440 400 360 320 280 240 200 160 120 80 40 0
Number of Deaths (thousands)

430

AMAZING

81 17
A lc oh ol A ID S

41

19
ed

14

30

Ve hi cl e

H om ic id e

Su ic id e

Sources: (AIDS) HIV/AIDS Surveillance Report, 1998; (Alcohol) McGinnis MJ, Foege WH. Review: Actual Causes of Death in the United States.JAMA 1993;270:2207-12; (Motor vehicle) National Highway Transportation Safety Administration, 1998; (Homicide, Suicide) NCHS, vital statistics, 1997; (Drug Induced) NCHS, vital statistics, 1996; (Smoking) SAMMEC, 1995

M ot or

D ru g

Sm ok in g

In du c

ANNUAL U.S. DEATHS ATTRIBUTABLE to SMOKING, 19972001


Percentage of all smokingattributable deaths*

Cardiovascular diseases Lung cancer Respiratory diseases Second-hand smoke Cancers other than lung Other

137,979 123,836 101,454 38,112 34,693 1,828

32% 28% 23% 9% 8% <1%

TOTAL: 437,902 deaths annually


Centers for Disease Control and Prevention. (2005). MMWR 54:625628.

2006 REPORT of the SURGEON GENERAL:

INVOLUNTARY EXPOSURE to TOBACCO SMOKE


Approximately 50,000 adults & infants die / year from secondhand smoke TWENTY YEARS later we FINALLY have evidencethe right of smokers to smoke ends There is no where their behavior affects 126 million nonsmokers insafe level of the health and well-being of the U.S. are exposed to second-hand others smoke. secondhand smoke Secondhand smoke contains more than 50 carcinogens
Surgeon General Koop, USDHHS Surgeon General Report, 1986

USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General.

FINANCIAL IMPACT of SMOKING


Buying cigarettes every day for 50 years @ $4.12 per pack Money banked monthly, earning 1.5% interest

$331,467

$220,978
Packs per day

$110,489
0 100 200 300 400

Hundreds of thousands of dollars lost

COMPOUNDS in TOBACCO SMOKE


An estimated 4,800 compounds in tobacco smoke
Gases (~500 isolated)

Particles (~3,500 isolated)


Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde

Nicotine Nitrosamines Lead Cadmium Polonium-210

Marketing Strategy: Light and Ultra-Light Cigarettes


The difference between Marlboro and Marlboro Lights

15mg tar, 1.1 mg nicotine

10mg tar, 0.8 mg nicotine

an extra row of ventilation holes


Image courtesy of Mayo Clinic Nicotine Dependence Center - Research Program / Dr. Richard D. Hurt
The Marlboro and Marlboro Lights logos are registered trademarks of Philip Morris USA.

The Safer Cigarette NOT!

Unveiling the SMOKING gun about Safe Cigarettes!

Face the Facts: Tobacco VS Marijuana

Prevalence of Marijuana use among adults = 4% compared to 21% for tobacco use

NIH, 2002 report, National Institute on Drug Abuse

Face the Facts: Tobacco VS Marijuana

Marijuana smoke contains 50 70% more carcinogens than tobacco smoke Marijuana smoke has 3-5 x the amount of tar and carbon monoxide One joint = 4 cigarettes
NIH, 2002 report, National Institute on Drug Abuse

Face the Facts: Tobacco VS Marijuana

Marijuana is an intoxicant makes you high/drunk

THC, tetrahydrocannabinol, is the active psychoactive ingredient that alters sense of reality & euphoria THC over stimulates cannabinoid receptors in the hippocampus Increase in THC content from 0.2% in 1960 to 12% in 2000

NIH, 2002 report, National Institute on Drug Abuse

Face the Facts: Tobacco VS Marijuana

Regardless of the form /delivery of Marijuana, it is illegal

Exception = medicinal purposes such as Marinol capsule used for pain / loss of appetite / nausea for pts with AIDS or cancer

NIH, 2002 report, National Institute on Drug Abuse

The Rest of the Story: Theres Other Tobacco Products


Chewing tobacco

Looseleaf Plug Twist

Snuff

Moist Dry

The Copenhagen and Skoal logos are registered trademarks of U.S. Smokeless Tobacco Company, and Red Man is a registered trademark of Swedish Match.

SPIT TOBACCO and HEALTH RISKS


Periodontal effects

Gingival recession Bone attachment loss Dental caries

Oral leukoplakia Cancer


Oral cancer Pharyngeal cancer


Image courtesy of the National Institute of Dental and Craniofacial Research

Other Tobacco Products

CIGARS

KRETEKS / CLOVE CIGARETTES

Other Tobacco Products

BIDIS

HOOKAH PIPE,

Gross pathology of lung showing centrilobular emphysema, characteristic of smoking

Image courtesy of the Centers for Disease Control and Prevention / Dr. Edwin P. Ewing, Jr.

Breaking the NICOTINE DEPENDENCE Cycle at ANY age!


A COMPREHENSIVE APPROACH = A Successful Framework for Quitting

The BEHAVIOR

The EMOTIONAL

The PHYSICAL

Automatic learned behavior with cigarettes

Role of cigarettes in life pleasure, stress, social

Physical addiction of cravings & withdrawals

Adapted from Legacys GSD&M Presentation 12/5/03

DOPAMINE REWARD PATHWAY


Prefrontal cortex
Within 7 11 seconds I feel good

Dopamine release

Nucleus accumbens Ventral tegmental area

Stimulation of nicotine receptors Nicotine enters brain

NICOTINE BEHAVIORAL EFFECTS: Do the Math!

An individual smokes 1 pack per day x 20 yrs 20 cigarettes / pack 10 puffs / cigarette = ?? puffs / day
200 HITS of THATs ____ NICOTINE per DAY

Now Multiply that # by days / year


73,000

THEN multiply that number by years smoking!


1.4 million

YIKES! No wonder it is SO difficult to QUITAverage attempts = 7-10 per smokers lifetime

NEUROCHEMICAL and RELATED EFFECTS of NICOTINE


N Dopamine I C O T I E
Pleasure, reward Arousal, appetite suppression Arousal, cognitive enhancement Learning, memory enhancement Mood modulation, appetite suppression Reduction of anxiety and tension Reduction of anxiety and tension Norepinephrine Acetylcholine Glutamate Serotonin

N -Endorphin
GABA

Benowitz. (1999). Nicotine Tob Res 1(Suppl):S159S163.

NICOTINE PHARMACODYNAMICS: WITHDRAWAL EFFECTS


Depression Insomnia Irritability/frustration/anger Anxiety Difficulty concentrating Restlessness Increased appetite/weight gain Decreased heart rate Cravings*
American Psychiatric Association. (1994). DSM-IV. Hughes et al. (1991). Arch Gen Psychiatry 48:5259. Hughes & Hatsukami. (1998). Tob Control 7:9293.

Most symptoms peak 2448 hr after quitting and subside within 24 weeks.

* Not considered a withdrawal symptom by DSM-IV criteria.

ASSESSING NICOTINE DEPENDENCE

How soon after you wake up do you smoke your first cigarette Do you find it difficult to refrain from smoking in restricted areas Which cigarette do you hate to give up most How many cigarettes do you smoke per day Do you smoke more frequently during the first hours after waking Do you smoke if you are so ill that you are in bed most of the day

Fagerstrm Test for Nicotine Dependence (FTND)

Scores range from 0 to 10; a score of greater than 5 indicates substantial dependence

The 5 As
ASK ADVISE ASSESS ASSIST ARRANGE
Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.

IF time does not allow. do 3 As and REFER

METHODS for INCREASING MOTIVATIONThe 5 Rs

with Motivational Interviewing Techniques

FOR INDIVIDUALS NOT READY TO QUIT YET: Tailor messages

RELEVANCE RISKS REWARDS ROADBLOCKS REPETITION

Fiore et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, 2000.

Quitting is HARD to do!


A COMPREHENSIVE APPROACH = A Successful Framework for Quitting

The BEHAVIOR

The EMOTIONAL

The PHYSICAL

Automatic learned behavior with cigarettes

Role of cigarettes in life pleasure, stress, social

Physical addiction of cravings & withdrawals

Adapted from Legacys GSD&M Presentation 12/5/03

Nicotine Replacement Therapy (NRT): RATIONALE for USE

Reduces physical withdrawal from nicotine Allows patient to focus on behavioral and psychological aspects of tobacco cessation It is NOT substituting ONE negative health behavior for another IMPROVES SUCCESS RATES!

LONG-TERM (6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS


30 25

Active drug Placebo


19.5 16.4

23.9 20.0 17.1

Percent quit

20 15

14.6 11.5 11.8 8.6 8.8 9.1 10.2

10 5 0

Nicotine gum Nicotine patch

Nicotine lozenge

Nicotine nasal spray

Nicotine inhaler

Bupropion

Data adapted from Silagy et al. (2004). Cochrane Database Syst Rev and Hughes et al., (2004). Cochrane Database Syst Rev.

FDA APPROVALS: SMOKING CESSATION


Rx nicotine inhaler Rx bupropion SR Rx transdermal nicotine patch Rx nicotine gum

2006 2002
Rx varenicline

1997 1996

1997

OTC nicotine lozenge

1991
Rx nicotine nasal spray

1984

Over the Counter NRT Products

Over the Counter NRT Products

Over the Counter NRT Products

Products Requiring a PRESCRIPTION

Products Requiring a PRESCRIPTION

Products Requiring a PRESCRIPTION

Products Requiring a PRESCRIPTION

COMPARATIVE DAILY COSTS of PHARMACOTHERAPY


Chantix Inhaler Gum Lozenge Bupropion SR Cigarettes (1 pack/day) Patch Nasal spray

$4.15 $6.07 $5.81 $5.31 $5.24 $4.12 $3.93 $2.66


0 2 4 6 8

Cost per day, in U.S. dollars

Breaking the NICOTINE DEPENDENCE Cycle


A COMPREHENSIVE APPROACH = A Successful Framework for Quitting

The BEHAVIOR

The EMOTIONAL

The PHYSICAL

Automatic learned behavior with cigarettes

Role of cigarettes in life pleasure, stress, social

Physical addiction of cravings & withdrawals

Adapted from Legacys GSD&M Presentation 12/5/03

WHAT IF
a patient asks you about your use of tobacco?

The RESPONSIBILITY of HEALTH PROFESSIONALS


If we do not act decisively, a hundred years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked.
DR. GRO HARLEM BRUNTLAND, FORMER DIRECTOR-GENERAL of the WHO
USDHHS. (2001). Women and Smoking: A Report of the Surgeon General. Washington, DC: PHS.

Help Make a DIFFERENCE

Start Referring TODAY! 1-800-QUIT NOW 1-706-721-8224

Slide resources/references available at http://rxforchange.ucsf.edu


http://nurses4tobaccocontrol.org THANK YOU