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Disclosures
I have nothing to disclose
TOBACCO USE IN UNDERSERVED SETTINGS
Maya Vijayaraghavan, MD MAS Division of General Internal Medicine San Francisco General Hospital
Acknowledgments Objectives
Review epidemiology of tobacco use Obtained slides/pictures from: Prevalence in low-income populations CDC Tips for former smokers campaign; Factors influencing tobacco use and cessation www.cdc.gov/tobacco/campaign/tips/ Health effects of tobacco Slides from Rx for change: Rxforchange.ucsf.edu CDC Tips for Former Smoker ’s Campaign Health benefits of tobacco cessation
Review treatment options Medications Counseling Policy interventions
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A PUBLIC HEALTH CHALLENGE OF OUR TIME: High prevalence low-income DISPARITIES IN TOBACCOATTRIBUTABLE populations DEATHS
Significant decline in the past 4 decades. Morbidity & mortality 2 to 4 times higher than Prevalence of smoking ~ 18% general population
3-5 times higher among underserved and vulnerable Tobacco-attributable diseases are leading causes of populations: morbidity & mortality Persons living below the federal poverty line Persons with a history of homelessness Underserved have not benefitted from population- Persons with a history of incarceration wide tobacco control efforts Persons with mental health disorders Persons with substance use disorders Racial/ethnic minorities Gender and sexual minorities
Schroder et al., Annu Rev Pub Health, 2010; CDC, MMWR, 2010; Vijayaraghavan et al. AJHP, 2015
Factors that influence tobacco use and cessation What are the different forms of tobacco?
Cigarettes: POLICY o Clean indoor air laws Most common form of tobacco in the U.S. o Cigarette taxes o Regulatory environment Usually sold in packs of 20 ENVIRONMENTAL o Smoke-free environments o Tobacco industry marketing Cigars: o ORGANIZATIONAL New tobacco products o Tobacco outlet density Have more nicotine than cigarettes. o One cigar can have enough nicotine to make a person SOCIAL Access to cessation care o Access to health care dependent
o Social norms o Care providers smoke Clove cigarettes: INDIVIDUAL o Media influences Mixture of tobacco and cloves o Mental health/substance use Have twice the nicotine compared to cigarettes o Self-efficacy
Glanz K.et al., Health Behavior and Health education: theory, research and practice; John Wiley & Sons; Chapter 20: Ecological models of health behavior Marlboro and Marlboro Light are registered trademarks of Philip Morris, Inc.; Adapted from Rx for change, UCSF, rxforchange.ucsf.edu
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What are the different forms of tobacco? What are the different forms of tobacco?
Bidis: Look like marijuana joints; come in candy flavors Smokeless or “““spit ””” tobacco include Higher levels of tar, carbon monoxide, and chewing tobacco and snuff (snus) nicotine than cigarettes Loose leaf More men than women Plug Waterpipe smoking (hookah): Twist Tobacco flavored with fruit pulp, honey Most commonly used by: Often used for longer amounts of time than Young adults (18-25 years old) cigarettes, so more smoke is inhaled American Indians & Alaskan Natives Residents of the southern U.S. and rural Pipes: areas Puffed into the mouth, typically not inhaled Least commonly used forms of tobacco Snuff
The Copenhagen and Skoal logos are registered trademarks of U.S. Smokeless Tobacco Company, and Red Man is a registered trademark of Swedish Match; Bidi image courtesy of the Centers for Disease Control and Prevention / Dr. Clifford H. Watson Hookah image courtesy of Mr. Sami Romman / www.hookah-shisha.com ; adapted from Rx. for change, Adapted from rx for change, UCSF, rxforchange.ucsf.edu rxforchange.ucsf.edu
Electronic nicotine delivery systems – Health effects of smoking – CDC Tips Electronic cigarettes for Former Smoker’s Campaign
Generally similar in appearance to cigarettes, • Cancer • Cardiovascular diseases cigars, pipes, or pens • Respiratory disease • Diabetes Battery-operated devices that create a vapor • Fertility/Reproductive problems for inhalation Simulates smoking but does not involve combustion of tobacco Also known as E-cigarette E-hookah, Hookah pen • HIV Vapes, Vape pen, Vape pipe • Teeth • Eyes Electronic nicotine delivery system (ENDS) • Immune function • All organs are involved…… http://www.cdc.gov/tobacco/campaign/tips/ Adapted from Rx for change, University of California, San Francisco, rxforchange.ucsf.edu
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Health benefits from smoking cessation
Time Since Quit Date
Circulation improves, walking becomes easier 2 weeks to 3 months Lung cilia regain normal function Lung function increases Ability to clear lungs of mucus increases 1 to 9 Treatment for tobacco months Coughing, fatigue, shortness of breath Excess risk of CHD decreases to decrease dependence 1 half that of a continuing smoker year
Lung cancer death rate drops to 5 Risk of stroke is reduced to that of people half that of a continuing smoker years who have never smoked Risk of cancer of mouth, throat, 10 esophagus, bladder, kidney, years pancreas decrease after Risk of CHD is similar to that of people 15 years who have never smoked
Adapted from Rx for change, University of California, San Francisco
Tobacco dependence – A 2 part Mr. P problem Mr. P is a 55 yo man with a previous history of Tobacco Dependence homelessness, substance use, traumatic brain injury, mild cognitive impairment, and Physiological Behavioral depression, who has been 1 ppd smoker for 40 years. The addiction to nicotine The habit of using tobacco
He lives in a board and care facility for persons with Treatment Treatment dual diagnoses where smoking is not allowed in indoors. Medications for cessation Behavior change program He is not ready to quit smoking, stating “I will never quit smoking ”. Treatment should address the physiological and the How would you counsel this patient? behavioral aspects of dependence.
Adapted from Rx for change, University of California, San Francisco; rxforchange.ucsf.edu
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Nicotine replacement therapy – Firstline Nicotine is very addictive FDA approved medications for smoking cessation Nicotine is the addictive substance is all forms of tobacco Reduces physical withdrawal from nicotine
Over 30% of people who smoke develop nicotine Eliminates the immediate, reinforcing effects of dependence. nicotine that is rapidly absorbed via tobacco smoke Less than 20% of people who use cocaine, heroin, Allows patient to focus on behavioral and psychological aspects of tobacco cessation or alcohol develop dependence
Nicotine causes pleasurable effects that reinforces tobacco use NRT products approximately double quit rates.
Nicotine cessation leads to severe withdrawal symptoms and craving that make tobacco cessation challenging
Adapted from Rx for change, University of California, San Francisco; Rxforchange.ucsf.edu
First-line FDA approved pharmaceutical therapy – Nicotine Replacement Therapy Bupropion and Varenicline
Psychotropic medications Polacrilex gum Nasal spray Nicorette ( OTC) BUPROPION/ZYBAN Nicotrol NS (Rx) Generic nicotine gum (OTC) Reduce withdrawal Reduce cravings Lozenge Inhaler Nicorette Lozenge (OTC) Nicotrol (Rx) Nicorette Mini Lozenge (OTC) Generic nicotine lozenge (OTC) Nicotine receptor partial agonist VARENICLINIE/CHANTIX Transdermal patch Reduce withdrawal NicoDerm CQ (OTC) Blocks dopaminergic reward Generic nicotine patches (OTC, Rx) pathway
Fiore MC, Jaén CR, Baker TB, et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service; Fiore MC, Jaén CR, Baker TB, et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service; Adapted from Rx for change, University of California, San Francisco; Rxforchange.ucsf.edu Adapted from Rx for change, University of California, San Francisco; Rxforchange.ucsf.edu
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Combination first line pharmaceutical therapy The efficacy of combination (not FDA approved, but evidence based) medications for smoking cessation Pharmacotherapy Estimated Abstinence rate Placebo 13.8 Bupropion + NRT First-line agents Transdermal patch + short-acting NRT (gum/spray) Nicotine gum 19.0 (16.5-21.9)
Nicotine inhaler 24.8 (19.1-31.6)
Second-line pharmaceutical therapy Nicotine lozenge 24.2 Nortriptyline Nicotine patch 23.4 (21.3-25.8) Clonidine Nicotine nasal spray 26.7 (21.5-32.7) Varenicline 33.2 (28.9-37.8)
Bupropion SR 24.2 (22.2-26.4)
Combination therapy
Patch + gum or inhaler 36.5 (28.6-45.3)
Nicotine patch + bupropion 28.9 (23.5-35.1)
Fiore MC, Jaén CR, Baker TB, et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service; Adapted from Rx for change, University of California, San Francisco; Rxforchange.ucsf.edu Data from: Fiore MC, Jaén CR, Baker TB, et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service.
Medications for individuals with Ecigarettes – to use or not mental illness to use? Persons with: Medications Depression • Bupropion Most common reasons for using e-cigarettes: • Nortriptyline Youth: flavors, experimentation Schizophrenia • Bupropion (need to be on stable antipsychotic regimen) Adults: cessation aid, circumvent indoor smoking Bipolar disorder • Bupropion (consider using a rules, flavors/taste lower dose at 150mg and monitor) Evidence is limited but what is known : Chronic pain • Nortriptyline E-cigs have not been shown to increase successful Anxiety/insomnia • Nortriptyline quitting • Clonidine E-cigs may serve as a gateway to cigarette Pregnancy • Guidelines do not recommend smoking among youth the use of any FDA-approved medications for treatment of E-cigs may encourage polyuse of tobacco products tobacco dependence
George 2002; Evins 2005; Data from: Fiore MC, Jaén CR, Baker TB, et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. Grana et al, 2014; King et al., 2015; Dutra et al., 2015; Popova et al., 2013
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Ecigarettes – to use or not Tobacco cessation requires to use? behavior change Fewer than 5% of people who quit without What to tell patients: assistance are successful in quitting for more than E-cigarettes are not approved by the FDA for smoking a year. cessation They are unregulated Few patients adequately PREPARE and PLAN for Safety is a concern their quit attempt. Encourage smoking cessation but suggest use of FDA Patients think they can just “““make themselves approved medications for cessation quit ”””
Behavioral counseling is a key component of treatment for tobacco use and dependence.
Grana et al, 2014; King et al., 2015; Dutra et al., 2015; Popova et al., 2013 Adapted from Rx for change, University of California, San Francisco; Rxforchange.ucsf.edu
Number of clinician interventions Effects of clinician interventions also help
With help from a clinician, the odds of quitting approximately doubles. Compared to smokers who receive assistance n = 37 studies from no clinicians, smokers who receive n = 29 studies assistance from two or more clinician types are 2.4–2.5 times as likely to quit successfully Compared to patients who receive no assistance from a clinician, patients who receive assistance are 1.7–2.2 for 5 or more months. times as likely to quit successfully for 5 or more months. 2.5 2.4 (1.9,3.4) 2.2 1.8 (2.1,3.4) 1.7 (1.5,2.2) 1.0 1.1 1.0 Estimated abstinence abstinence Estimated rate at 5+ months
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008; Rx for change, University of California, San Francisco Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008; Rx for change, University of California, San Francisco, rxforchange.ucsf.edu
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The 5 A ’’’s 5A ’’’s – ctd.
What should you ask? ASK Do you ever smoke cigarettes or use any form of tobacco? ADVISE How many cigarettes do you smoke every day? How soon after you wake up do you smoke your first cigarette? ASSESS Where do you smoke?
ASSIST
ARRANGE
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008; Adapted from Rx for change, University of California, San Francisco; Rxforchange.ucsf.edu
5A ’’’s – ctd. Brief Counseling: Ask, Advise, Refer
Build motivation to change behaviors by eliciting (5Rs): ASK about tobacco USE Relevance – Why is quitting important? Risks – What are harms of tobacco? ADVISE tobacco users to QUIT Rewards – What are the benefits of tobacco? Roadblocks – What are the barriers to quitting? to other resources Repetition – Repeat the message at each encounter REFER Arrange for follow-up after a quit attempt Most people try multiple times before they can quit smoking successfully: Client receives assistance from ASSIST Best predictor of successful quitting is the length of the other resources, with follow-up counseling arranged last quit attempt ARRANGE
Adapted from Rx for change, University of California, San Francisco; Rxforchange.ucsf.edu
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Brief Counseling: Ask, Advise, Refer (cont ’’’d) Mr. P Brief interventions have been shown to be effective Build awareness – Tobacco log, connect with health symptoms In the absence of time or expertise: Encourage small steps – reducing consumption, practice quit attempts Ask, advise, and refer local group programs or the toll-free quitline 1-800-QUIT-NOW /1-800-NO-BUTTS/1-855-DEJELO-YA Enlist support of case manager/caretaker Provide a rx. for smoking cessation –wellbutrin+NRT
He eventually cut down to 10 cpd
Congratulated on efforts but did not stop there… This brief intervention can be achieved in less than 1 minute.
Adapted from Rx for change, University of California, San Francisco; Rxforchange.ucsf.edu
Policy interventions ## Smoke# Case Presentation of Mr. N free policies
55 yo man with a history of episodic cocaine Smoke-free policies very effective population-based use: strategy
Smoke-free homes –voluntary no smoking at home is a Smokes 10 cpd powerful intervention Thinking about smoking cessation but not ready to Smoke-free homes are associated with: commit to setting a quit date. Reduced secondhand smoke exposure Smokes in his apartment Decreased consumption How would you counsel this patient? Increased cessation Reduced relapse to smoking
IARC Handbooks of Cancer Prevention, Tobacco Control, Vol. 13: Evaluating the effectiveness of smoke-free policies (2009: Lyon, France); Vijayaraghavan et al., AJPH, 2013; Mills et al., AJPM, 2011; Gilpin et al., NTR, 2006.
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Policy interventions – Smoke#free Policy Interventions: Media Homes Campaigns
Prevalence of smoke-free homes is low among low-income populations. Department of Housing and Urban Health recently proposed a rule for all public housing authority-managed housing to: Implement indoor smoke-free policies Restrict smoking outdoors to more than 25 feet from buildings
Smokefree policies in 3100 PHAhousing will impact 1.2 million lowincome housing units in the United States
Vijayaraghavan et al., AJPH, 2013; Mills et al., AJPM, 2011; Gilpin et al., NTR, 2006; HUD ruling 2015
Policy interventions – implications Substance use and smoking for clinical practice cessation
Ask smokers whether they smoke indoors. 2-3 times more smoking with alcohol/illicit Ask all non-smokers whether they are exposed to substance use secondhand smoke. Heavy smoking: What can you tell patients? Increases use of cocaine and heroin Secondhand smoke is linked causally with cancer, CV Makes alcohol use more pleasurable disease, respiratory disease. 50% those in substance use treatment die from Implement a smoke-free home. tobacco-related diseases Personalize message: target teens; pregnant women; parents Quitting smoking may increase long-term abstinence from all substances by 25% Quitting smoking doesn’t interfere with recovery from other substances
Hurt et al., 1996; Prochaska et al., 2006
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Case Presentation of Mr. N – Many unanswered What we did questions 55 yo man with a history of cocaine dependence Specific interventions for homeless adults? who smokes 10 cpd in his apartment How to capitalize on the forced quit that occurs in Congratulated him on his interest in smoking jail/prison once released? cessation Advised him to implement a smoke-free home Interventions for mentally ill or substance use? Felt that smoke-free home helped him cut down Getting ready to make a quit attempt Will smoke-free policies in public housing increase Working on stopping episodic cocaine use rate of evictions?
Take home messages Smoking cessation resources Ask smokers whether they smoke indoors http://rxforchange.ucsf.edu/ -- Resources for smoking cessation Advise people to not smoke or use e-cigs indoors http://www.bhwellness.org/resources/toolkits/ -- Ask about tobacco use and advise to quit Resources for smoking cessation http://www.cdc.gov/tobacco/campaign/tips/resources/ -- Ensure that patients have resources for cessation CDC Tips from former smokers campaign Refer to resources http://www.nobutts.org/ -- California Smokers ’ Helpline Provide these resources http://smokingcessationleadership.ucsf.edu -- Smoking cessation leadership center Follow-up on tobacco use at every encounter http://www.epa.gov/indoor-air-quality-iaq/secondhand- Ask about exposure to secondhand smoke tobacco-smoke-and-smoke-free-homes -- Environmental Protection Agency http://www.no-smoke.org -- Americans for nonsmoker’s rights http://www.changelabsolutions.org -- Changelab solutions
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