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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 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 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 than .  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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