Provider Training 02/2008 Paul Zemann PHSKC paul.zemann@kingcounty.gov

Overview We will discuss: • Secondhand smoke, smoking and asthma • An effective approach you can use to counsel families about tobacco cessation • How to use this approach • Tobacco cessation resources © 2007 TCRC, All Rights Reserved.

How Does Tobacco Smoke Trigger Asthma? • When a person inhales tobacco smoke, irritating substances settle in the moist lining of the airways. These substances can cause an attack in a person who has asthma. • In addition, tobacco smoke damages tiny hair-like structures in the airways called cilia. Normally, cilia sweep dust and mucus out of the airways. Tobacco smoke damages cilia so they are unable to work, allowing dust and mucus to accumulate in the airways. • Smoke also causes the lungs to make more mucus than normal. As a result, even more mucus can build up in the airways, triggering an attack. © 2007 TCRC, All Rights Reserved.

Is Second-Hand Smoke Harmful to a Person with Asthma? • Second-hand smoke is the combination of smoke from a burning cigar or cigarette and smoke exhaled by a smoker. • Inhaling second-hand smoke, also called "passive smoke" or "environmental tobacco smoke," may be even more harmful than actually smoking. That's because the smoke that burns off the end of a cigar or cigarette contains more harmful substances (tar, carbon monoxide, nicotine, and others) than the smoke inhaled by the smoker. • Second-hand smoke is especially harmful to people who already have asthma. When a person with asthma is exposed to second-hand smoke, he or she is more likely to experience the wheezing, coughing and shortness of breath associated with asthma. © 2007 TCRC, All Rights Reserved.

Can Smoking Harm My Child? • Second-hand smoke harms children with asthma even more than adults. • When a child is exposed to tobacco smoke, his lungs become irritated and produce more mucus than normal. Since children's airways are smaller, the side effects of second-hand smoke affect them faster and can also affect lung function in later life. • Children of parents who smoke are also more likely to develop lung and sinus infections. These infections can make asthma symptoms worse and more difficult to control. © 2007 TCRC, All Rights Reserved.

Can Smoking Harm My Unborn Child? • Smoking harms an unborn child in many ways. Nicotine, the addictive substance in tobacco products, is carried through the mother's bloodstream directly into the baby. • Children of mothers who smoked during pregnancy are more likely to have lung problems and are 10 times more likely to develop asthma. Smoking during pregnancy has also been linked with low-birth weight newborns, premature births, and sudden infant death syndrome (SIDS). © 2007 TCRC, All Rights Reserved.

How Can Tobacco Smoke Be Avoided? • If you smoke, quit. Quitting isn't always easy, but there are many programs and methods to help. Ask your doctor to help you find the one that is best for you. If your spouse or other family members smoke, help them understand the dangers of smoking and encourage them to quit. • Do not allow smoking in your home or your car. • Do not let anyone smoke around you or your child © 2007 TCRC, All Rights Reserved.

The Opportunity • Most tobacco users want to quit • Half make a serious attempt each year • 80% see a healthcare provider each year • 80,000 fewer adult smokers since 1997 © 2007 TCRC, All Rights Reserved.

Provider Impact The National Cancer Institute projects that if providers assisted even 10% of their tobacco-using patients in quitting, the number of tobacco users in the U.S. would drop by 2 million people annually Fiore et al., 1990 © 2007 TCRC, All Rights Reserved.

PHS Recommendations The Public Health Service Guidelines advise providers to: • Counsel people on tobacco cessation using a tool called the Brief Tobacco Intervention © 2007 TCRC, All Rights Reserved.

Evidence for Brief Intervention • Substantial evidence* shows that Brief Tobacco Interventions are effective • The Surgeon general states that if every provider used the brief tobacco intervention every time they saw a tobacco user, we would reduce tobacco use by 20% • * Selected Evidence: • Schroeder – What to do with a patient who smokes (JAMA 2005) • Public Health Service Guidelines – US Department of Health and Human Services (June 2000) • U.S. Preventive Services Task Force, “Counseling to Prevent Tobacco Use” (November 2003) © 2007 TCRC, All Rights Reserved.

Traditional Tools The 5A Intervention ASK about tobacco use.  ADVISE to quit.  ASSESS willingness to make a quit attempt.  ASSIST in quit attempt.  ARRANGE follow-up. © 2007 TCRC, All Rights Reserved.

New Tools The 2A and R Intervention ASK about tobacco use  ADVISE to quit  REFER to an internal or external entity that completes the rest of the 5As ASSESS ASSIST ARRANGE  Schroeder (2005), JAMA. © 2007 TCRC, All Rights Reserved.

Brief Intervention - 2As and R Advise people to quit – this doubles the chances that they will try to quit “Quitting tobacco is the single most important thing you can do for your health and your families health, we can help you identify some community resources.” © 2007 TCRC, All Rights Reserved.

Brief Intervention - 2As and R Refer to community resources or to the Washington State Tobacco Quit Line for help in quitting tobacco King County Resources are identified in the list you will be receiving today © 2007 TCRC, All Rights Reserved.

Be aware that: • Tobacco dependence is chronic • Tobacco users may have other addictions • The physical and psychological environment is part of the message • Community resources are available • We have interventions that work © 2007 TCRC, All Rights Reserved.

Three-Link Chain 1. Biological addiction to nicotine • Feeling of pleasure, decrease in anxiety • Lasting chemical changes in brain • Quitting produces withdrawal symptoms © 2007 TCRC, All Rights Reserved.

Tobacco Delivered Nicotine – a Chemical Cocktail • Acetaldehyde:: synergistic addictive effects • Ammonia::increase speed and efficiency of nicotine absorption • Leuvenalic acid, chocolate and menthol:: may increase ease of inhalation and deep lung absorption • Menthol:may also provide a cue for Pavlovian conditioning • Physical engineeringby particle physicists results in more rapid and efficient absorption of nicotine and toxins • Glycerin: can form particles to enable deep lung exposure © 2007 TCRC, All Rights Reserved.

Small Amounts of Exposure are Dangerous • Scientific evidence indicates that there is no risk-free level of exposure to secondhand smoke. Breathing even a little secondhand smoke can be harmful to your health. © 2007 TCRC, All Rights Reserved.

Secondhand smoke causes lung cancer • Secondhand smoke is a known human carcinogen and contains more than 50 chemicals that can cause cancer. • Concentrations of many cancer-causing and toxic chemicals are potentially higher in secondhand smoke than in the smoke inhaled by smokers. © 2007 TCRC, All Rights Reserved.

Secondhand smoke causes heart disease • Breathing secondhand smoke for even a short time can have immediate adverse effects on the cardiovascular system, interfering with the normal functioning of the heart, blood, and vascular systems in ways that increase the risk of heart attack. • Even a short time in a smoky room can cause your blood platelets to become stickier, damage the lining of blood vessels, decrease coronary flow velocity reserves, and reduce heart rate variability. • Persons who already have heart disease are at especially high risk of suffering adverse affects from breathing secondhand smoke, and should take special precautions to avoid even brief exposure. © 2007 TCRC, All Rights Reserved.

Secondhand smoke causes acute respiratory effects • Secondhand smoke contains many chemicals that can quickly irritate and damage the lining of the airways. • Even brief exposure can trigger respiratory symptoms, including cough, phlegm, wheezing, and breathlessness. • Brief exposure to secondhand smoke can trigger an asthma attack in children with asthma. • Persons who already have asthma or other respiratory conditions are at especially high risk for being affected by secondhand smoke, and should take special precautions to avoid secondhand smoke exposure. © 2007 TCRC, All Rights Reserved.

Secondhand smoke can cause sudden infant death syndrome • Smoking by women during pregnancy has been known for some time to cause SIDS. • Infants who are exposed to secondhand smoke after birth are also at greater risk of SIDS. • Children exposed to secondhand smoke are also at an increased risk for acute respiratory infections, ear problems, and more severe asthma. Smoking by parents causes respiratory symptoms and slows lung growth in their children. © 2007 TCRC, All Rights Reserved.

Seperation and Ventilation Does not Work • The American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), the preeminent U.S. standard-setting body on ventilation issues, has concluded that ventilation technology cannot be relied on to completely control health risks from secondhand smoke exposure. © 2007 TCRC, All Rights Reserved.

continued…. • Conventional air cleaning systems can remove large particles, but not the smaller particles or the gases found in secondhand smoke. • Operation of a heating, ventilating, and air conditioning system can distribute secondhand smoke throughout a building. © 2007 TCRC, All Rights Reserved.

Nicotine/other addictive drugs • 85+% who use nicotine, use daily • 10% of cocaine/alcohol users • Withdrawal not life-threatening • Can be for alcohol • Most severe consequences delayed © 2007 TCRC, All Rights Reserved.

Provider Training 02/2008 Paul Zemann PHSKC paul.zemann@kingcounty.gov