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10 Vijayaraghavansmokingces 3/12/2016 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 1 3/12/2016 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 2 3/12/2016 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 3 3/12/2016 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 4 3/12/2016 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 5 3/12/2016 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
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