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Tobacco Related Disease and Cessation

Tobacco Related Disease and Cessation. Eric L. Johnson, M.D. Physician Consultant North Dakota Tobacco Quitline Department of Family and Community Medicine University of North Dakota School of Medicine and Health Sciences Grand Forks, ND. Objectives.

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Tobacco Related Disease and Cessation

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  1. Tobacco Related Disease and Cessation Eric L. Johnson, M.D. Physician Consultant North Dakota Tobacco Quitline Department of Family and Community Medicine University of North Dakota School of Medicine and Health Sciences Grand Forks, ND

  2. Objectives • Tobacco is a major contributor to death and disability in North Dakota • Tobacco Use is not just a Habit, it is a Nicotine Addiction • Effective Strategies exist to help people stop using Tobacco

  3. Tobacco Related Diseases

  4. State by State Smoking % Adults who smoke BRFSS 2006, CDC

  5. 500 400 300 No.(000s) 200 100 0 Annualsmokingdeaths Environ-mentaltobaccosmokedeaths AllWorldWar II Annualautoaccidents VietnamWar AIDS1983-1990 Annualmurders Annualheroin,morphine& cocainedeaths Tobacco Related Deaths-A Perspective Adapted from Dr. R. Hurt, Mayo Nicotine Dependence Center Used By Permission

  6. 13.2-14.5 years of life lost due to smoking

  7. Smoking Causes Death Smoking causes approximately • 90% of all lung cancerdeaths in men • 80% of all lung cancerdeaths in women • 90% of deaths from chronic obstructive lung disease (COPD) CDC

  8. Smoking Causes Death Compared 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 CDC

  9. 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 -HS students: *26% in 2003, 27% in 2005, 22% in 2007 ^10% in 2003, 12.7% in 2005, 10.2% in 2007 (BRFSS 2008) (YRBS 2005,2007)

  10. North Dakota Department of Health Division of Tobacco Prevention and Control

  11. North Dakota Department of Health Division of Tobacco Prevention and Control

  12. 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

  13. Tobacco Use in North Dakota -Between 2001 and 2008, Adult smoking rates in North Dakota dropped from 23.2% to 18.1%, similar to national trends -Healthy People 2010 Goal (Now): 12% or less -52% report cessation attempts annually Behavioral Risk Factor Surveillance System (BFRSS)

  14. 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.

  15. North Dakota spends $691 per capita on direct medical expenditures andlost productivity due to smoking

  16. 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

  17. Secondhand Smoke Deaths United States • Lung cancer – 3,000 deaths annually • Ischemic heart disease – 35,000 deaths annually North Dakota • 80-140 deaths annually

  18. Tobacco and Cardiovascular Disease(Heart Disease and Stroke)

  19. Coronary Heart Disease • Leading cause of death in the USA • Smoking attributable mortality 30% • Most of decline in incidence is because of  smoking rate • ~100,000 CVD deaths due to smoking and >35% occur before age 65 • 2-6X  risk of sudden death in smokers • Over 1.6 million coronary procedures/year American Heart Association Report of the U.S. Surgeon General 2004

  20. Cerebrovascular Disease-Stroke • 600,000 cases/year in U.S. • 30 % fatality rate at one year • Similar risk factors as Coronary Heart Disease

  21. Smoking and Cardiovascular Disease • Quitting smoking will lower risk substantially in about 5 years • Smokers with established CVD lower risk of subsequent events by quitting smoking

  22. Tobacco and Cancer

  23. U.S. 1997-2001 MMWRJuly 1, 2005 / 54(25);625-628 US Surgeon Generals Report 2004

  24. U.S. 1997-2001 MMWRJuly 1, 2005 / 54(25);625-628 US Surgeon Generals Report 2004

  25. Lung Cancer • Leading cause of cancer death in men and women • Smoking causes 87% of lung cancers in the USA • Smoking increases risks of all four major types of lung cancer • Cigar and pipe smoking associated with increased risk • 5-year survival for lung cancer 15% • Reduced risk with smoking cessation • Average 2 year cost per patient - $48,000 MMWR, ACS

  26. Relative risk of lung cancer mortality Years post smoking cessation American Cancer Society

  27. Tobacco Use and Oral Cancers • ACS - 28,900 cases & 7,400 deaths annually • 90% are Squamous Cell Carcinoma (SCC) • Worldwide - 300,000 cases annually • Ranks 6th among all cancers • 3rd most common site in males in developing countries Vokes EE, NEJM 1993 • Tobacco causes of >85% oral cancer deaths in males Johnson N, J Dent Educ 2001 • High rate of morbidity & mortality • 5-yr average survival < 50%

  28. COPD and Smoking • 4th leading cause of death • Accounts for > 100,000 deaths/yr • Symptomatic improvement and lung function preservation with tobacco cessation Report of the U.S. Surgeon General 2004 American Lung Association

  29. Tobacco Cessation Improves Surgical Outcomes • Cardiovascular complications • Respiratory complications • Wound-related complications • Many elective procedures require tobacco cessation

  30. Special Populations

  31. Pregnancy and Tobacco Use • Fourfold increase in small for gestational age; Increased prematurity • Twice the rate of spontaneous abortions • Increased risk of abruptio placentae, placenta previa, premature and prolonged rupture of membranes Russell, T, et al Nicotine & Tobacco Research, Vol6, Supp 2. Apr. 2004 Gabbe: Obstetrics 4th ed 2002 Pediatrics 2005; 116: 462-467

  32. Pregnancy and Tobacco Use • Intrauterine growth restriction • Positive association between smoking and sudden infant death syndrome (SIDS) and increased respiratory illnesses in children Russell, T, et al Nicotine & Tobacco Research, Vol6, Supp 2. Apr. 2004 Gabbe: Obstetrics 4th ed 2002 Pediatrics 2005; 116: 462-467 • Possible Association with maternal smoking and ADHD Am J Psych 2003 Jun;160(6):1028-40

  33. Pregnancy and Tobacco Cessation • Medications controversial • NRT Category D • Weigh risk vs. benefit • Counseling is a key component, possibly low dose intermittent NRT (gum, lozenge)

  34. North Dakota Providers:Do you offer tobacco cessation options to pregnant patients? 2009 Unpublished, NORTHSTAR,UNDSMHS Dept Family and Community Medicine

  35. North Dakota Providers: What types of counseling do you offer pregnant patients for tobacco cessation? 2009 Unpublished, NORTHSTAR,UNDSMHS Dept Family and Community Medicine

  36. Smoking and Diabetes • Strong Association between smoking history and development of Type 2 Diabetes • Now thought to be an independent risk factor, like obesity • Several large studies to date with more recent interest • Already a high risk CVD population • Glucose control may be worse

  37. Tobacco Use and Mental Illness • Tobacco use in patients with a psychiatric diagnosis ~41% • Tobacco use patients without a psychiatric diagnosis ~20% Lasser, et al JAMA 2000

  38. Smoking in the Chemically Dependent Population • Smoking rate in the general population ~20% • Smoking rate in the chemically dependent population ~80+% • Smoking is more deadly to chemically dependent population: 4 times the death rate of non-smokers 51% of deaths from tobacco 33% of deaths from drugs or alcohol CDC 2005; Walsh, etal Drug & Alcohol Review (24) 2005; Hurt, et al Alcoholism: Clin & Exp Res (18) 1994

  39. Smoking Cessation in Mental Illness and Chemical Dependency • Nicotine Replacement Therapy may be best choice • Other medications (buproprion, varenicline) have psychiatric effects that should be considered

  40. Tobacco Cessation

  41. 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)

  42. Pharmacotherapy(Medications)For Tobacco Cessation

  43. Nicotine Withdrawal • Symptoms -anger/irritability -depression/anxiety -insomnia -increased dream activity • Peak in 1st week, last 2-4 weeks • ~50% experience significant withdrawal symptoms • Most patients underestimate withdrawal symptoms Hughes Nic Tob Res 2007 Madden Addiction 1997 Stages J Clin Psych 1996

  44. Pharmacotherapy • Nicotine replacement therapy (NRT) • Gum • Patch • Spray • Inhaler • Lozenge • Bupropion (Zyban, Wellbutrin) • Varenicline (Chantix) • Other medications in development

  45. Nicotine replacement therapy • Replace the nicotine supplied by cigarettes • Conversion: Each cigarette provides 1 mg of nicotine • Combination therapy • Most people underdose NRT, or don’t take it long enough

  46. Nicotine Replacement Therapy (NRT) • 1mg for each cigarette smoked • 10 cigs=10mg • 20 cigs=20mg • 40 cigs=40mg • Note: may exceed label recommendations

  47. Bupropion • Inhibits reuptake of dopamine & norepinephrine • Exact mechanism of action in smoking cessation is not clear • Initially developed as an antidepressant • Promotes smoking cessation even in the absence of depression

  48. Varenicline(Chantix) • A partial nicotine receptor antagonist • Binds to the nicotine receptors in the brain • “Feeds the need” for nicotine at the CNS level • Essentially a “form of NRT”

  49. Varenicline • Most common side effects - nausea (16-30%) - insomnia (18-19%) - abnormal dreams (9-13%) • Weight-neutral • New FDA warning-monitor for changes in mood/mental status/behavior

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