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Promoting Smoking Cessation  in Women

Promoting Smoking Cessation  in Women. Hal Strelnick, MD Dept of Family and Social Medicine David Lounsbury, PhD Bruce Rapkin, PhD Dept of Epidemiology and Population Health Department of Obstetrics & Gynecology Grand Rounds 10/20/2009.

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Promoting Smoking Cessation  in Women

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  1. Promoting Smoking Cessation in Women Hal Strelnick, MD Dept of Family and Social Medicine David Lounsbury, PhD Bruce Rapkin, PhD Dept of Epidemiology and Population Health Department of Obstetrics & Gynecology Grand Rounds 10/20/2009

  2. Tobacco use is the leading preventable cause of premature death in the US • Tobacco is responsible for: • 21% of coronary heart disease deaths • 30%+ of all cancers • 70-80% of oral cavity & pharyngeal cancers • 90% of lung cancer deaths • stomach, cervix, kidneys, pancreas, AML & others • 90% of COPD deaths The Toll of Tobacco Use

  3. Maternal Smoking during Pregnancy • Healthy People 2010 goal:  2% prevalence of smoking among pregnant women • "Maternal smoking remains the single most important modifiable cause of poor pregnancy outcome in the United States, accounting for a significant portion of babies with low birth weight, pre-term births, and perinatal death such as sudden infant death syndrome (SIDS)." • Institute of Medicine, Ending the Tobacco Probem:  A Blueprint for the Nation, 2007

  4. Same toxic exposure as First-Hand Smoke • Health effects include: • Lung cancer, heart disease, eye & nasal irritation • Suggested relationships to cervical cancer, miscarriage & decreased lung function • Effects on children • Causes & worsens asthma • Increased risk of Sudden Infant Death Syndrome (SIDS) • Direct effect on bronchitis, pneumonia & otitis media • Increased probability of becoming smokers Environmental Tobacco Smoke (aka Second-Hand Smoke) Max et al., 2009

  5. Epidemiological Overview Women and Smoking

  6. Declining Rates of Smoking in NYC NYCDHMH EpiQuery HealthData website (http://a816-health3ssl.nyc.gov), accessed 5-13-09

  7. Smoking Prevalence Trend for Men & WomenNew York City vs. Bronx, 2002-2008 Source: NYCDOHMH EpiQuery, Annual Community Health Surveys, 2002-2008

  8. Male 18-24 45-64 Black Asian Bklyn Queens Reductionin Smoking Prevalence in New York City by Demographic Groups, 2002-2008 65+ White Staten Island 25-44 Hispanic Bronx Female Manhattan Other Source: NYCDOHMH Tobacco Control Program, Annual Community Health Surveys

  9. Bronx Neighborhoods NYC Department of Health Female Smoking Prevalence 2006-2007 11.7% 12.7% 23.3% South Bronx 17.6% 18.5%

  10. Prevalence of Smoking Before, During, and After pregnancy MMWR, 2009: 58(SS04); 1-29

  11. Prevalence of Smoking during Pregnancy MMWR, 2009: 58(SS04); 1-29

  12. Prevalence of Smoking during Pregnancy by Race and Ethnicity MMWR, 2009: 58(SS04); 1-29

  13. Prevalence of Smoking during Pregnancy, by Maternal Age Group MMWR, 2009: 58(SS04); 1-29

  14. Postpartum Relapse (Mullen et al., 1990)

  15. Percentage of Women Relapsing* Post-Partum after Quitting during Pregnancy MMWR, 2009: 58(SS04); 1-29 * Assessed 4 months after delivery

  16. Tobacco Use and Cancer Riskin Women

  17. + 4000 MORE chemicals!! What’s in a Cigarette?

  18. Cancer Risk and Tobacco Use in Women • Smoking is directly responsible for 80 percent of lung cancer deaths in women in the U.S. each year • In 1987, lung cancer surpassed breast cancer as the leading cause of cancer deaths among women in the US • Compared to nonsmokers, men who smoke are about 23 times more likely to develop lung cancer and women who smoke are about 13 times more likely • Smoking causes about 90% of lung cancer deaths in men and almost 80% in women • For women, the risk of cervical cancer increases with the duration of smoking HHS, 2004

  19. Tobacco Use and Cervical Risks • Increased risk with tobacco use and cervical cancer when HPV is present • Dose-adjusted increased risks seen • Results in increased virion synthesis and genome copies • Nicotine has several potential effects on oviduct and oviduct function • Effects oocyte complex pickup, embryo transport, and implantation • Tobacco  use has positive relation on clinically diagnosed PMS incidences •  Incidence rates and disease are dose-adjusted •  Supported by research of tobacco effects on FSH, estrogen, and progesterone metabolite levels

  20. Treating Tobacco Use and Dependence in Women

  21. Significant evidence that smoking causes: • Stillbirth • Preterm birth • Placental abruption • SIDS • Fetal growth retardation • Associated with increased risks of: • Spontaneous abortion • Ectopic pregnancies • Placenta previa Health Risks during Pregnancy MMWR, 2004; Cnattingius, NTR, 2004

  22. Children of smokers have increased risk of: • SIDS • Hospitalization within first year • Serious respiratory infections • Bronchiolitis, pneumonia • Otitis media • Asthma • Language delays • Hyperactivity Health Risks after Pregnancy

  23. Pharmacologic addiction to nicotine • Psychological dependence on smoking • Behavioral cues • Mood regulation, coping with stress, emotions • Concern about weight gain • Women tend to gain slightly more weight than men • Assist with diet and exercise Why Women Continue to Smoke

  24. Differences Pharmacological Addiction:Tobacco Dependence vs. Other Chemical Dependencies • Compulsive use • Continued use despite harm • Impaired control over drug use • Tolerance • Withdrawal • Mediated via dopamine release • Rapid release • Rapid reinstatement of dependence • No behavioral intoxication or adverse behavioral outcomes • Does not cause other mental disorders • Giving up or reducing activities to use is rare • High intensity of use • Little euphoria • Spending lots of time in obtaining/using/recovering from effects is rare • Dependence is rare in adult non-daily users • Pro-social beneficial effects Similarities

  25. Young (< 25 years) • Non-Hispanic white • ≤ 12 years education • Unmarried • Annual income < 15k • Underweight • Unintended pregnancy • First-time pregnancy • Initiated prenatal care later • Medicaid enrolled • Enrolled in WIC during pregnancy Psychological Dependence:Characteristics among Pregnant Smokers MMWR, 2009: 58(SS04); 1-29

  26. Spontaneous quitter during pregnancy • 45% relapse within 3 months • 60-70% relapse within 6 months • 80% relapse within year • Partner or household member who smokes • 44% have partner who smokes • 33% have household member who smokes Psychological Dependence:Characteristics of Relapsed Smokers Post-partum Merzel et al., 2009. Maternal Child Health Journal.

  27. Brief counseling intervention by health care providers effectively promotes smoking cessation • Counseling intervention especially important among pregnant smokers: • Park et al., 2004: • 66% report being counseled on quitting • 37% reported materials given • Park, 2007 • 29% reported provider discussed medication use • 10% of smokers used medication in pregnancy Importance of the Role of Providers in Smoking Intervention (Fiore et al., 2008; Park et al., 2007)

  28. Pharmacological Interventions

  29. The efficacy & safety of pharmacological approaches during pregnancy are unknown • No medication has been observed in a sufficiently large number of pregnancies to determine what might occur with large-scale use • Use of counseling & social support • Successful RCTs:Significant Other Supporter (SOS), Quit Together, self-help programs • Cochrane Review (July 2009) • 56 RCTs (N=20,000) & 9 cluster randomized trials6% smoking reduction, 17% LBW & 14% preterm birth reduction, 54 gm mean increase in birthweight • No effective relapse RCTs Smoking Cessation Interventions During Pregnancy

  30. Non-nicotine medication (C) • Patch * • Gum * • Lozenge * • Oral Inhaler ^ • Nasal Spray ^ • Bupropion ^+ • (Zyban/Wellbutrin) • Varenicline ^+ • (Chantix) Tobacco Cessation Medications Nicotine Replacement (D) *Available OTC ^ prescription only + FDA Black Box warning as of 7/1/09

  31. Reasons for NOT using NRT • Doubles the success rate • Treats nicotine withdrawal • Helps patient feel more comfortable • Safe • Patient receiving same drug (nicotine) in a less addictive form over a relatively short period • Medical conditions requiring caution/physician input • i.e. recent MI, pregnancy, current arrythmia • Age • Under 18s require physician/parental input • Specific issues • Allergy to patches • Personal aversion to medication • Questionable efficacy • i.e. those smoking less than 10pd Use of NRT in Non-pregnant Women Reasons for using NRT

  32. Nicotine is the addictive part of tobacco smoke but NOT the most dangerous part • People do NOT generally become addicted to medication • People DON’T use enough medication or stop TOO EARLY • Medications are SAFE and EFFECTIVE • Plan on minimum of 2 months of medication • Combinations • Work better than single medications • Use Long acting + Short acting Important Points about NRT

  33. Plasma Nicotine concentrations for Nicotine-containing products Time (minutes)

  34. Nicotine Delivery Comparison

  35. In non-pregnant smokers, NRT and Bupropion each double cessation rates, compared to behavioral methods alone • In very limited studies in pregnant women, NRT was not associated with adverse outcomes, but did have a short-term influence on fetal breathing movements and fetal heart rate variability • Smoking nicotine has adverse effects on the fetus • Smoking exposes women to nicotine plus other chemicals that are harmful Important Points about Pharmacology

  36. Training, Technical Assistance, and Resources for Clinicians Bronx BREATHES NYSDOH Tobacco Cessation Center

  37. Bronx BREATHES Team Hal Strelnick, MD – Principal Investigator Barbara Hart, MPA – Project Manager David Lounsbury, PhD – Co-Investigator Shadi Nahvi, MD – Co-Investigator Claudia Lechuga, MS – Research Associate Shaniyya Pinckney – Academic Detailer Bronx Einstein Alliance for Tobacco-free Health

  38. Bronx BREATHES:Supportive Services for Clinicians • Tobacco treatment training: 5As, 5Rs, pharmacotherapy, NYSDOH Quitline • Academic detailing: Tailored consultation regarding the design and implementation of systems that identify tobacco users and manage their treatment • Linkage to provider and patient services: Promote referral to NYSDOH Quitline and local smoking cessation treatment services in the Bronx

  39. Transtheoretical Model: Stages of Change Prochaska and DiClemente

  40. 1. Ask about tobacco use • Identify and document tobacco use status for every patient at every visit • 2. Advise to quit • In a clear, strong and personalized manner urge every tobacco user to quit • 3. Assess willingness to quit • Is the tobacco user willing to make a quit attempt at this time? • 4. Assist in quit attempt • If willing to quit, use counseling, pharmacotherapy, and/or other resources to help patient quit • 5. Arrange follow up • Schedule follow-up contact, preferably within the first week after the quit date Brief Counseling Intervention: the 5 A’s (Fiore et al., 2008)

  41. 1. Relevance to quitting smoking • Most helpful to make it personal and specific • 2. Risks associated with cont’d smoking • Highlight risks that seem most relevant to the patient • 3. Rewards to being tobacco-free • Identify potential benefits to being smoke-free • 4. Roadblocks to successfully quitting • Address elements of treatment that could alleviate barriers to quitting • 5. Repetition of assessment • Unmotivated patients should be asked each and every visit Motivational Interviewing: the 5 R’s (Fiore et al., 2008)

  42. Does the patient now use tobacco? Algorithm for Brief Intervention Yes No Is the patient now ready to quit? Did the patient once use tobacco? No Yes Yes No Promote motivation Provide treatment Prevent relapse* Encourage continued abstinence *Relapse prevention interventions not necessary if patient has not used tobacco for many years and is not at risk for re-initiation. Fiore et al., 2008.

  43. Too busy • Lack of expertise • No financial incentive • Most smokers can’t/won’t quit • Stigmatizing smokers • Respect for privacy • Negative message might scare away patients • Smoker Provider Barriers Fiore et al., 2008

  44. NYS Medicare and Medicaid • Medicare: • Covers counseling visits (3-10 minutes and >10 minutes) and CO expiration measures • Covers all NRT (except lozenges) and Non-NRT Medications • Two courses of smoking therapy per recipient, per year • One course = 90-day supply (an original order and 2 refills, 30 days each) • Medicaid (for pregnant women): • Covers counseling visits (3-10 minutes and >10 minutes) • Must be used with one of these ICD-9 Codes: • 630-677, V22, V23, V28

  45. Reimbursement Codes

  46. Patient Referral Services: Phone Counseling NYS Quitline: 1-866-NY-QUITS • Services: • Free telephone counseling in English, Spanish and several other languages • Free NRT • Referrals to local counseling and cessation programs • Free educational materials • Efficacy of Quitlines • Multiple calls: OR 1.41 (1.27-1.57) • Efficacy for long term cessation • Effective at reaching racial/ethnic minority smokers Stead et al., Cochrane Library, 2007

  47. NYS Fax-to-Quit Referral Service • Available in paper and online forms • Provider-referred patients are contacted by Quitline services and offered the same services as above • Progress report sent back to you

  48. Clinical and TranslationalResearch in Tobacco Treatment

  49. Future Tobacco Research in Smoking and Pregnancy • Relapse prevention with pregnant women and women who have recently given birth • Effectiveness of psychosocial treatment provided via nonface-to-face modalities (quitlines or web-based programs) • Safety and effectiveness of cessation meds during pregnancy for the women and the fetus, and during child nursing • Effectiveness of economic incentives to promote and sustain quitting • Linking preconception, pregnancy and post-partum interventions • Co-morbidity studies (tobacco use, depression/anxiety) among pregnant women Fiore et al., 2008

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