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Tobacco Cessation In Special Populations

Tobacco Cessation In Special Populations

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Tobacco Cessation In Special Populations

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  1. Tobacco Cessation In Special Populations Eric L. Johnson M.D. Assistant Professor Department of Family and Community Medicine University of North Dakota School of Medicine and Health Sciences

  2. Objectives • Identify the scope of tobacco’s impact in North Dakota • Discuss common disease states associated with tobacco use • Discuss and apply tobacco cessation needs for special populations

  3. Special Populations • Diabetes- already at high risk for cardiovascular disease, smoking as a cause/exacerbation of diabetes • Pregnancy- poorer pregnancy outcomes • Mental Illness/Chemical Dependency- - high utilization, difficult to treat • Adolescents- Difficult to engage, limited data on medications • Native Americans- High utilization, barriers

  4. Overview of Tobacco

  5. 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

  6. 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

  7. Secondhand Smoke Deaths United States • Lung cancer – 4,000 deaths annually • Ischemic heart disease – 45,000 deaths annually North Dakota • 80-140 deaths annually CDC

  8. State by State Smoking % Adults who smoke BRFSS 2009, CDC

  9. Tobacco Use in North Dakota • ~100,000 ND adults and ~8,000* HS students smoke cigarettes • ~20,000 ND adults and ~3,800^ HS students use spit tobacco (BRFSS 2008) (YRBS 2005,2007,2009)

  10. Tobacco Use in North Dakota • Between 2001 and 2009, Adult smoking rates in North Dakota dropped from 23.2% to 18.6% • Highest West Virginia 25.6% • Lowest Utah 9.8% • About half of smokers report cessation attempts annually Behavioral Risk Factor Surveillance System (BFRSS) MMWR

  11. 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.

  12. General Issues in Smoking Cessation • Triggers • Mood changes • Withdrawal symptoms (most smokers underestimate) • Weight gain • Lack of support • Exposure to other smokers

  13. Tobacco Cessation Counseling • Brief counseling (i.e., 5A’s) • Classes • Quitline/Quitnet/Quitplan • 3rd party payer programs

  14. Pharmacotherapy • Nicotine replacement therapy (NRT) • Bupropion (Zyban, Wellbutrin) • Varenicline (Chantix) • First-line therapies USPHS Guidelines 2008

  15. Smoking and Diabetes

  16. 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

  17. Does smoking cause diabetes? • Growing evidence points to smoking as an independent risk factor for developing diabetes • Large prospective studies with multivariate adjustments still do point to a causal link

  18. Smoking and Diabetes Risk • Women’s Health Study RR 1.42 AJPH 1993 • Men’s Health Professionals Study RR 1.94 BMJ 1995 • Osaka Study RR 1.47- 1.73 Diabetes Med 1999 • Physician’s Health Study RR 2.1 Am J Med 2000 • Cancer Prevention Study 1 RR 1.45-2.1 I Jour Epi 2001

  19. Smoking and Diabetes • The Translating Research Into Action for Diabetes (TRIAD) Study • Smoking increased relative risk of all cause mortality of 1.44 McEwon, et al Diabetes Care 2007

  20. Passive (Second Hand)Smoking and Diabetes • The High-Risk and Population Strategy for Occupational Health Promotion (HIPOP-OHP) study • Relative risk of type 2 Diabetes 1.81 with secondhand exposure • Relative risk of type 2 Diabetes 1.99 for active smokers Hayashino, et al Diabetes Care 2008

  21. Effects of smoking on diabetes • Increased random and fasting glucose • Increased HbA1C • Increased insulin resistance • All these despite a lower average BMI • Recent study showed 9.8% of youth with diabetes smoke Reynolds, et al ADA meeting abstract 2008 Haire-Joshu, et al Diabetes Care 1999

  22. Medications for Smoking Cessation in Diabetes • NRT • Buproprion • Varenicline (Chantix) • All can be used in diabetes, avoidance of weight gain important

  23. Tobacco and Diabetes • Smoking is a cause of type 2 diabetes • Smoking worsens diabetes control • Smoking increases risk of CVD and other complications • Smoking cessation is critical in diabetes • Consider appropriate medications • Refer to ND Quitline/Quitnet, MN Quitplan, other local resources

  24. Tobacco and Pregnancy

  25. Tobacco Cessation in Pregnancy • Benefits in pregnancy and long term health (interventions in younger women) • Reduce Cardiovascular Complications • Reduce Lung Disease • Reduce Cancer • Reduce Type 2 Diabetes • Economic benefit for individual and society

  26. Smoking in Pregnancy • Smoking in pregnancy higher in North Dakota than national average: 18% vs. 11% • Smokers tend to be from lower socioeconomic and educational classes • WIC smoking population as high as 40%+ in North Dakota North Dakota Department of Health

  27. Smoking in Pregnancy • ~75% of pregnant smokers desire quitting • ~25-30% actually quit during pregnancy • ~50% resume after pregnancy • Smoking Cessation is most successful prior to pregnancy Ruggiero L, et al Addict Behav. 2000 Mar-Apr;25(2):239-51 Ebert LM Fahey K Women Birth. 2007 Dec;20(4):161-8 Tong VT, et al Am J Prev Med. 2008 Oct;35(4):327-33.

  28. Complications of Smoking in Pregnancy • 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 George L, et al Epidemiology. 2006 Sep;17(5):500-5 Faiz AS, Ananth CV.J Matern Fetal Neonatal Med. 2003

  29. Complications of Smoking in Pregnancy • Intrauterine growth restriction • Stillbirth • Ectopic pregnancy • Infertility • Poor wound healing/surgical outcomes Russell, T, et al Nicotine & Tobacco Research, Vol6, Supp 2. Apr. 2004 Gabbe: Obstetrics 4th ed 2002 Högberg L, Cnattingius G. BJOG. 2007 Jun;114(6):699-704.

  30. Fetal/Child Effects of Maternal Smoking in Pregnancy • Sudden infant death syndrome (SIDS) and increased respiratory illnesses in children • Possible Association with maternal smoking and ADHD/Behavioral Disorders • Congenital Anomalies (i.e., cleft lip/palate, cardiac) Linnett KM, et al Pediatrics 2005; 116: 462-467 Malik S, et al Pediatrics 2008 Apr;121(4):e810-6 Shi M, et al Am J Hum Genet. 2007 Jan;80(1):76-90

  31. Smoking Cessation Interventions in Pregnancy • Brief Office Counseling • Smoking Cessation Class (i.e., Public Health) • Third Party Payer programs • Quitlines • Online programs (i.e., Quitnet) • Pharmacologic

  32. Pharmacotherapy for Pregnant Smokers • NRT- Category D. Secreted in breast milk. Crosses placenta • Buproprion (Wellbutrin, Zyban)- Category B. Metabolites in breast milk. Risk of seizure (low). Increase spontaneous abortion 1st trimester? • Varenicline (Chantix)- No data (yet) Oncken CA, Kranzler HR Nic Tob Res Nov 2009

  33. Pharmacotherapy for Pregnant Smokers • USPHS 2008 more limited recommendations vs USPHS 2000 • ACOG 2005: NRT for heavy smokers if other nonpharmacologic interventions fail

  34. Pharmacotherapy for Pregnant Smokers • NRT use must be risk vs benefit -heavy smoker, relapsers, other risk ? (i.e. CVD risk factors) -if NRT used, intermittent (gum, lozenge) -higher birth weight? • Buproprion? 1 study shows benefit * • Varenciline- not recommended presently *Chan B et al J Add Dis (24) 19-23 2005

  35. Pharmacotherapy for Pregnant Smokers • Smoking, Nicotine, and Pregnancy Trial • Currently underway (UK study) • Projected publication is 2013

  36. Smoking Cessation Interventions in Pregnancy • Pregnancy affords a great opportunity • Multiple short term followup clinic visits • Phone calls/e-mail/quitline/quitnet • ASK every time • Options every time • North Dakota data encouraging

  37. Tobacco Use and Mental Illness

  38. 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

  39. Tobacco Use and Mental Illness • Lifetime quit rates for ever smokers with a psychiatric diagnosis 16%-26% • Lifetime quit rates for ever smokers without psychiatric diagnosis ~42% • Persons with mental illness consume 30-50% of all tobacco sold in the U.S. Lasser, et al JAMA 2000 Fagerstrom and AubinCurr Med Res Op 2009

  40. Mental Illness Smoking Rates • Schizophrenia 80%+ • Depression 40-60% • Bipolar Disorder 40-70% • Anxiety Disorders 20-50% • PTSD 50-65%

  41. Factors Influencing Smokingin Mental Illness • Nicotine may improve symptoms of schizophrenia • Nicotine may improve symptoms of depression • Withdrawal from nicotine may exacerbate symptoms in mental illness Dalak, et al Am J Psych 1999 Malpass and Higgs Psychopharm 2007

  42. Smoking Cessation Interventions in Mental Illness • Brief Office Counseling (5 A’s) • Smoking Cessation Class (i.e., Public Health, Lung Association) • Third Party Payer programs • Quitlines • Online programs (i.e., Quitnet) • Pharmacologic

  43. Considerations/Complications of Smoking Cessation Therapy In Mental Illness • Tobacco can lower serum levels of some psychiatric drugs • Induction of CYPIA2 • Therefore, cessation may alter serum levels of some psychiatric drugs • Monitoring for side effects, change in status, etc important Fagerstrom and Aubin Curr Med Res Op 2009

  44. Management of Emergent Psychiatric Symptoms in Tobacco Cessation • Monitor for symptoms • NRT +/- buproprion if appropriate (depression) • Adjustment of other psych medications • Cognitive behavioral therapy (CBT) • Motivational Interviewing • Varenicline? Can exacerbate some symptoms

  45. Medications for Tobacco Cessation in Mental Illness • NRT: Be aware of interactions with psych meds, but more data • Buproprion: May be useful to co-manage depression, depends on other meds used • Varenicline: Not a lot of data, but can exacerbate some symptoms Fagerstrom and AubinCurr Med Res Op 2009

  46. Tobacco Use and Chemical Dependency

  47. Tobacco and Chemical Dependency • We treat all other aspects of chemical dependency simultaneously • Nicotine (tobacco) is an addictive drug with adverse health effects • Treat chemical dependency, need to lower risk of dying prematurely from a tobacco related disease in recovery

  48. Nicotine Dependence 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

  49. Benefits of Smoking Cessation in CD Treatment • Smoking tobacco and drinking alcohol are strongly inter-related Gulliver, et al J Stud Alc 2000 • Urges to smoke = Urges to drink Cooney, et al Psych Addict Beh 2007 • Increased smoking = Increased drinking Barrett, et al Drug Alc Dep 2006 • Other concomitant addictions are treated