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Smoking:

Smoking:. The Talk You’ve Never Heard. Michael B. Honan, MD CardioVascular Associates, PC Brookwood Medical Center December 30, 2008. Disclosures. None. Objectives. I want to convince you that smoking cessation is:

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Smoking:

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  1. Smoking: The Talk You’ve Never Heard Michael B. Honan, MD CardioVascular Associates, PC Brookwood Medical Center December 30, 2008

  2. Disclosures • None

  3. Objectives • I want to convince you that smoking cessation is: • Far and away the most impactful thing smokers can do to help their long-term health and life expectancy. • “This is much more important to how long you live and how healthy you are than whether we open your artery or not.” • I want you to have the information needed to give you the greatest chance of success in this endeavor. Motivation is the single biggest factor determining whether or not someone will quit smoking.

  4. Approaches to the Discussion • Be sure they know that you understand that: • This is their decision, • that your role is only to give them the information that you have that they might benefit from, and • that you will do what you can for them regardless of what they choose to do. • Your message might not resonate until the 6th or 7th time you have this conversation, but it is your role to allow them the opportunity to reconsider their decision to smoke. • They may not succeed in quitting until their 6th or 7th attempt.

  5. Public Health Service Guidelines – The 5A Model • Ask about smoking. • Advise one to quit. • Assess willingness to quit. • Assist those willing to quit. • Arrange 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.

  6. Approaches to the Discussion • Help them to understand that they can quit. • There are more former than current smokers in the US. • Up to 85% of smokers after MI have quit smoking. • It’s never “too late” to quit smoking. • The older the smoker and the longer the smoking duration, the greater the chances of quitting. • Encourage them to have this conversation with themselves. • “List the reasons you want to continue to smoke, and the reasons you might not want to start back.”

  7. Individualize your discussion for each patient.

  8. Smoking and Mortality • In 1928, smoking linked to lung cancer1. • In 1938, smoking linked to mortality overall2. • The first Surgeon General’s Report labeled smoking “the single most important source of preventable morbidity and premature mortality.” in 1964. • Lombard HL, Doering CR. N Engl J Med 1928;198:481-7. • Pearl R. Science 1938;87:216-7.

  9. Surgeon General’s Report May 2004 • 438,000 deaths per year- still the #1 cause of preventable death in the US. • 19% of all deaths!!! • Reduces lifespan of the average smoker by: • 13.2 years for males • 14.5 years for females • 5,522,257 years of potential life lost in the US in 2001.

  10. Deaths Attributed to Smoking Morbid Mortal Wkly Rep 2003;52:842-4.

  11. Risk Factors • Unmodifiable • Age • Family history of early CAD • Male gender • Genetic factors • African-American • Modifiable • Cigarette smoking • Hypertension • Cholesterol-HDL, LDL, • Triglycerides • Diabetes • Overweight • Poor diet • Lack of regular exercise • Cocaine/crack use

  12. Cardiovascular Risk Factors 8422 Men Age 40-64 Followed for 72,011 person-years Smoking > 1 ppd Smoking > 1 ppd Weight > 129% ideal vs < 112% Cholesterol > 268 vs < 219 Systolic BP > 150 vs < 130 Diastolic BP > 94 vs < 80 Relative Risk of Major Coronary Events There are also interactions between risk factors. The Pooling Project Research Group. J Chron Dis 1978;31:201-306.

  13. Cardiovascular Effects • Impairs endothelial function – vasoconstriction. • Pro-thrombotic • Increases fibrinogen, hs-CRP, and homocysteine levels. • Reduces anti-thrombin III. • Increases platelet aggregation. • Causes catecholamine release. • Increases lipolysis, fatty acid release, VLDL levels. • Lowers HDL cholesterol. • Reduces the oxygen content of blood. • Carbon monoxide binds irreversibly to hemoglobin. • Impaired pulmonary function – raises A-a gradient. Bazzano LA. Ann Intern Med 2003;138:891-7.

  14. Cardiac Effects • Atherosclerosis • Promotes coronary plaque formation. • Promotes plaque rupture/ acute coronary syndromes. • Promotes premature coronary bypass closure and restenosis. • Reduces coronary blood flow and promotes coronary vasospasm – cath lab demos1,2. • Nicotine increases oxygen utilization and demand by increasing heart rate & BP – increases ischemia3. • Arrhythmias-PVCs, APCs, atrial fib, MAT, VT, V-fib. • Cardiomyopathy independent of atherosclerosis4. • Kaijser L, Berglund B. Clin Physiol 1985;5:541-52. 2. Maouad J, et al. Catheter Cardiovasc 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.

  15. Cardiovascular Effects • 33.5% of smoking-related deaths1. • Coronary artery disease (X 2.5)2 – angina, myocardial infarction, arrhythmias, sudden death, heart failure. • Cerebrovascular disease – stroke (X 3),3 hemorrhagic stroke (X 3.29)4, and TIA. • Peripheral vascular disease (X 7.3)5 – claudication, leg ulcers, impaired wound healing, gangrene, aneurysms of aorta and other vessels, venous insufficiency (X 2.4).6 • Interaction with other risk factors – diabetes, lipids, hypertension, estrogen, genetics. • 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 Health 2002;26:26:291-24. 6. Gourgo S, et al. Am J Epidemiol 2002;155:1007-15.

  16. Relative Risk Cardiovascular http://apps.nccd.cdc.gov/sammec/edit_risk_data.asp

  17. Smoking Cessation after MI • Occurred in 56.2% at 6 months and 56.8% at a year among 19 hospitals in the Premier Registry. 1 • Results in a 36-46% reduction in mortality.2,3 • Reduction in recurrent nonfatal MI. • Better control of other cardiovascular risk factors. • Better functional status. • Thus smoking cessation counseling a CMS, JCAHO performance measure. 1. Reeves GR, et al. Arch Intern Med 2008;168:2111-7. 2. Critchley, et al. Cochrane Database Syst Rev. 2003:CD003041.doi:10.1002/14651858CD003041. 2. Wilson K, et al. Arch Intern Med 2000;160:939-44.

  18. ACC/AHA 2007 STEMI Guidelines Secondary Prevention • Ask, advise, assess, and assist patients to stop smoking – I (B) • Clopidogrel 75 mg daily: • PCI – I (B) • no PCI – IIa (C) • Statin goal: • LDL-C < 100 mg/dL – I (A) • consider LDL-C < 70 mg/dL – IIa (A) • Daily physical activity 30 min 7 d/wk, minimum 5 d/wk – I (B) • Annual influenza immunization – I (B)

  19. Predictors of Smoking Cessation after MI • PREMIER Registry- 19 centers, 639 smokers • Discharge prescription for cardiac rehab: OR=1.80 (1.17-2.75). • Treated at a facility that offered an inpatient smoking cessation program with at least one month of support after discharge: OR=1.71 (1.03-2.83). • Depressive symptoms: OR=0.57 (0.36-0.90). Dawood N, et al. Arch Intern Med 2008:168:1961-7.

  20. Deaths Attributed to Smoking Morbid Mortal Wkly Rep 2003;52:842-4.

  21. Respiratory Tract Effects Causes peribronchiolar inflammation and fibrosis, bronchospasm, increases mucosal permeability, impairs mucociliary clearance, changes pathogen adherence, disrupts respiratory epithelium, impairs immune response, carcinogenic. • Acute and chronic sinusitis • Acute and Chronic Obstructive Pulmonary Dis (X 13.1) • Asthma, emphysema (24%) chronic bronchitis (49%), pneumonia, interstitial lung disease, bronchiolitis, pulmonary hypertension, respiratory failure, tuberculosis (X 4.5) Arcavi L. Arch Intern Med 2004;164:2206-16.

  22. Relative Risk - Respiratory http://apps.nccd.cdc.gov/sammec/edit_risk_data.asp

  23. Lung Cancer • About 28% of smoking-attributable deaths. • In 2000 • in US, 87% of the 184,000 new cases of lung cancer1 • 850,000 lung cancer deaths worldwide2. • 3000 US lung cancer deaths attributed to secondhand smoke3. • 10-year risk for a 68yo man with a 100-pack-yr history is 15%. • Continued smoking shortens survival time5. • 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 Inst 2003;95:470-8.

  24. Lung Cancer – Dose Effect Wynder EL, Stellman SD. J Natl Cancer Inst 1979;62:471-7.

  25. Cancer Effects • Carcinogenic – 60 chemical carcinogens • Responsible for a third of all cancer deaths in western countries. • Incidence of lung cancer deaths in the US has been steeply declining over the past ten years, first in men, and now in women as well. Sacco AJ, et al. Lung Cancer 2004;Suppl 2:S3-9.

  26. Relative Risk - Cancer http://apps.nccd.cdc.gov/sammec/edit_risk_data.asp

  27. Gastrointestinal Effects • Chronic destructive periodontal disease – the main risk factor. Relative risk X 5-20 vs never smoker1. • Increased risk and severity, slower healing and greater recurrence of gastritis, gastroesophageal reflux, peptic ulcer disease (X 3.4-4.1)2. • Increased Crohn’s Disease (X 2.0) and ischemic bowel. 1. Bergstrom J. Odontology 2004;92(1):1-8. 2. Mallamapalli A, et al. Med Clin N Amer 2004;1431-51.

  28. Smoking and Infection • Cause structural changes in the respiratory tract and a decrease in immune response. • 30% increased WBC, increased CD8+ counts, reduced IgG, IgA, IgM. • reduced CD4+ counts in bronchoalveolar fluid. • Inhibition of PMN chemotaxis and migration, NK cell activity. • Decreases release of IL-1, IL-2, IL-6, TNF-α, IFN-γ. • 2- to 5-fold increased risk of invasive pneumococcus. • 1.5- to 2.2-fold risk of common cold. • 1.4- to 2.4- fold influenza risk and more severe. • Varicella, HPV, HIV prevalence and severity increased • Increased risk of tuberculosis, especially important in underdeveloped countries. • Increased risk of meningococcal disease, bronchitis, and otitis media in children exposed to secondhand smoke. Arcavi L. Arch Intern Med 2004;164:2206-16.

  29. Women and Smoking • Smoking reduces the average life expectancy1 by: • 14.5 years for females. • 13.2 years for males. • Facilitates the metabolism of estrogen, increasing risk of cardiovascular disease, osteoporosis (80% higher fracture risk), cervical cancer, and wrinkles. • Increased susceptibility of women to develop lung cancer in response to smoking which is more virulent and at an earlier age than in men2. In 2000, exceeded breast, uterine, and ovarian cancer death combined in women. ¼ of all cancer deaths in women. • Doubles the risk of DVT and PTE among OCP users3. 1. US Surgeon General May 2004. 2. Reuters January 31, 2005. 3. Reichert VC, et al. Med Clin N Amer 2004;88:1467-81.

  30. Women and SmokingThe Nurses’ Health Study • 104,519 nurses age 30-55 followed 1980-2004. • At baseline (1980), • 45.7% never smoked • 26.0% past smokers • 28.3% current smokers • In 2002, only 8% of those alive were current smokers. • Among current smokers, 64% of all deaths were directly attributable to smoking. Among former smokers, 28% of deaths attributable to smoking. Kenfield SA, et al. JAMA 2008;299:2037-47.

  31. Mortality Among WomenNurses’ Health Study Smoking Status Cigarettes per Day Kenfield SA, et al. JAMA 2008;299:2037-47.

  32. Causes of Death in WomenCardiovascular & “Unrelated Cancer” Kenfield SA, et al. JAMA 2008;299:2037-47.

  33. Causes of Death in WomenRespiratory & “Related Cancer” Lung, AML, bladder, kidney, cervix, esophagus, lip, mouth, pharynx, pancreas, stomach, larynx Kenfield SA, et al. JAMA 2008;299:2037-47.

  34. Smoking and Pregnancy • Increased infertility (X 1.36), spontaneous abortions, ectopic pregnancies (X 1.9). • Increases prematurity and fetal death. • Low birth weight doubles. • Increased risk of placenta previa, pre-eclampsia. • Sudden Infant Death Syndrome – 10% of all infant deaths. • Negative toddler behavior –cranky, restless, sick more often, learning problems. Morbid Mortal Wkly Rep 2002;51:i-iv,1-13.

  35. Pregnancy & Long-Term Vascular Damage to Children • Atherosclerosis in Young Adults study-births from 1970-1973, follow-up at 28.4 years. • At birth offspring lighter and shorter at birth • Heavier (p=.001) and higher SBP (p=.02) as adolescents. • Heavier (p=.004), shorter (p=.02), more likely to smoke (p=.006) as adults. • At age 28, Carotid IMT • 13.4 μm greater if mother smoked (p=0.001) • 12.4 μm greater if father smoked (p=.002) • Greater if both smoked (p=.001) Geerts C, et al. Arterioscler Thromb Vasc Biol 2008: DOI: 1161/ATVBAHA.108.173229.

  36. Drug Metabolism • Enhanced clearance of: • theophyllline, tacrine, propranolol, diazepam, chlordiazepoxide, estrogen • Reduces the metabolism of drugs by the cytochrome P450 pathway: • warfarin • Reduces levels of fluvoxine, imipramine. • Increases levels of clozapine. Metz CN, et al. Med Clin N Amer 2004;1399-1413.

  37. Other Medical Problems • Increases the risk of: • Dementia & Alzheimer’s (X 2) and cognitive dysfunction (X 1.5). • Insulin resistance and risk (X 1.45-1.94) and severity of diabetes. • Grave’s Disease and ophthalmopathy. • Cataracts. • Severity of rheumatoid arthritis. • Impotence (X 2.5). • 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.

  38. Smokeless Tobacco • Snuff, chewing, or “spit” tobacco. • Used by 5 million adults and more than 750,000 adolescents. • Increases risk of oral cancer, dental problems such as receding gums, bone loss, and bad breath. • Increased heart rate by 16 bpm, blood pressure by 10 mm Hg, and epinephrine by 50% among 16 healthy young men. Wolk R. J Amer Coll Cardiol 2005;45:910-4.

  39. Secondhand Smoke • Secondhand smoke exposure is responsible for 38,000 deaths including 3000 lung cancer deaths annually in the US1. • Living with a smoker increases the risk of ischemic heart disease death by 30-57%3-5. • 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.

  40. Secondhand Smoke • May rapidly precipitate atherothrombotic events. • Increases CRP, fibrinogen, and ox-LDL similar in magnitude to smokers. • Increases platelet aggregation, augments MMP activity, thus plaque destabilization • Decreases HDL, causes mitochondrial damage, insulin resistance. • 30 minutes SHS impairs coronary endothelial function and increases aortic stiffness similar to smokers. • Reduces heart rate variability. Barnoya J, et al. Circulation 2005;111;2684-98

  41. Clean Indoor Air & Acute Coronary Syndromes • In Helena, MT, there was a 40% reduction in the number of heart attacks with a clean indoor air policy, that returned to prior levels when it was overturned.2 • In Pueblo, CO, there was a 27% reduction in heart attacks over the 18-month period after a comprehensive public Smoke-Free Air Act = a reduction by 70/100,000/year vs. no change in Colorado Springs during the same period. 3 • In Scotland, in the year after smoke-free legislation in March 2006 there was a 17% reduction in hospital admissions for acute coronary syndromes (95% CI 16-18%) vs a 4% reduction in England. This was a reduction of 14% among smokers, 19% among former 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.

  42. Secondhand Smoke • Pre-school age children exposed to their parents’ smoke are 20% more likely to get middle ear infections. • Maternal smoking ½ ppd increases COPD risk 70% in their children2. • March 8, 2005 California Air Resources Board links passive smoking to a 26-90% increased risk of breast cancer3. 2. Reichert VC, et al. Med Clin N Amer 2004;88:1467-81. 3. Ritter J. USA Today March 9, 2005:7D.

  43. States with Restrictions as of 12/31/07 • Restrictions in private-sector worksites in 37 (39) states. • Restrictions in restaurants in 41, but not in: AL. Smoke-free in 21 states. • Restrictions in bars in only 20. Smoke-free in 13 states. • As of 2003, 77% of US workers in a smoke-free workplace. MMWR 2008 57(20):549-52.

  44. American Cancer Society Alabama Survey Of 500 registered Alabama voters who participated: • 78% responded in favor of a law making all Alabama workplaces smoke-free. • 95% viewed secondhand smoke as at least some kind of health hazard. • 92% agreed no one should be exposed to secondhand smoke in the workplace. • 79% responded that it is the government's responsibility to promote and protect public health. • 81% said they were likely to vote in the next election. Performed by Little rock-based Opinion Research Associates January 2008

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

  46. Other ImpactsPersonal Expense • Cigarettes- At $3.27/pack, 1ppd X 50 years will cost $59,677 in 2005 dollars. • Duke economist Frank Sloan estimates at $40/pack or $220,000 for a 24YO man in The Price of Smoking. • Cost of cigarettes + excise taxes. • Life and property insurance. • Medical care for the smoker and his family. • Lost earnings due to acute illness and disability. • Lost receipt from private pensions, social security and Medicare due to early death. • Reduced quality of life due to illness and disability. • Lost retirement (life expectancy about 67 years). WalMart April 5, 2005. Duke Magazine 2005;91:17. Sloan FA, et al. The Price of Smoking 2004. The MIT Press, Cambridge, MA.

  47. Other ImpactsSocietal Expense • $76 billion societal medical expense: • $27 billion ambulatory • $19 billion nursing home • $17 billion hospital • $6.4 billion prescription drugs • $5.4 billion other • $98 billion in lost productivity costs annually. • $204 billion total cost. http://apps.nccd.cdc.gov/sammec/computations.asp

  48. Smoking and Health-Related Quality of Life in Old Age • 1658 healthy white men in Helsinki Businessman Study 40-55 YO enrolled 1974, surveyed 2000 • Never smokers lived ten years longer, and their extra years were of better quality. • Health-related quality of Life (HRQoL) measured with Rand 36-Item Health Survey Strandberg AY, et al. Arch Intern Med 2008: 168:1968-74

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