1. CIGARETTE SMOKING, CARDIOVASCULAR DISEASE RISK, AND IMPLEMENTATION STRATEGIES FOR SMOKING CESSATION Adapted and Modified from: Luepker RV, Lando HA. Tobacco Use and Passive Smoking, in: Wong ND, Black HR, Gardin JM, eds. Preventive Cardiology, Mc Graw Hill, 2000 and NANCY HOUSTON MILLER, R.N., B.SN., Stanford University Roger Blumenthal, MD et al ACC Prevention Guidelines 2007

2. Smoking Statement Issued in 1956 by American Heart Association

• It is the belief of the committee that much greater knowledge is needed before any conclusions can be drawn concerning relationships between smoking and death rates from coronary heart disease. The acquisition of such knowledge may well require the use of techniques and research methods that have not hitherto been applied to this problem.

• Circulation 1960; vol. 23

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3. Arch Intern Med . 2003;163:23012305. Surgeon Generals Health Consequences of Smoking, 2004. CDC/NCHS. Tobacco-Related Mortality, Fact Sheet. CDC.gov/tobacco. February 2004. Heart Disease and Stroke Statistics2005 Update, AHA. MMWR, Vol. 51, No. 14, 2002, CDC/NCHS. 33.5% of smoking-related deaths among Americans are cardiovascular-related Male smokers die an average of 13.2 years earlier than male nonsmokers Female smokers die an average of 14.5 years earlier than female nonsmokers Current cigarette smoking is a powerful independent predictor of sudden cardiac death in patients with CHD Cigarette smoking results in a two- to threefold risk of dying from CHD Smoking: Mortality

4. CHD Risk by Cigarette Smoking. Filter Vs. Non-filter. Framingham Study . Men 25 cigarettes/day

Acute MI and sudden death strongly associated with cigarette smoking.

Cigarette smoking has additive effect to CHD risk above lipids, obesity, diabetes, and hypertension

14. Cohort Studies of Environmental Tobacco Smoke and CHD RR (95% CI) Population Location,Date Source F 1.9 (1.1-3.3) 32046 US 1997 Kawachi M 1.2 (1.1-1.4) F 1.1 (-.96-1.3) 309599 US 1996 Steenland 2.7 (1.3-5.6) 2278 UK 1995 Tunstall-Pedoe M 0.97 (0.7-1.3) F 0.99 (0.8-1.2) 2916 US 1995 Layard 2.0 (1.2-3.4) 7987 UK 1989 Hole M 1.3 (1.1-1.6) F 1.2 (1.1-1.4) 19035 US 1988 Helsing 2.2 (0.7-6.9) 1245 US 1987 Svendsen 2.7 (0.7-10.5) 695 US 1985 Garland 1.2 (0.9-1.4) 91,540 Japan 1984 Hirayama 15. Environmental Tobacco Smoke and CHD

35,000-40,000 deaths annually from acute MI are associated with environmental tobacco exposure, significantly more than due to lung cancer.

Recent meta analysis of passive smoking incorporating home-based and workplace studies (1699 cases) showed relative risk of 1.49 (1.29-1.72)

Sidestream smoke released into the environment may be more toxic and nonsmokers who are exposed regularly develop various physiologic changes and are more sensitive than regular smokers.

Lower HDL-C and platelet abnormalities, higher CO levels and lower exercise tolerance are noted.

16. Prevention and Intervention Strategies in Youth

School-based prevention programs

• Social environment / influences

Community-based prevention programs

• May enhance effects of school-based programs

State and federal prevention initiatives

• Anti-tobacco media campaigns

• Restrictions on tobacco advertising

• Restrictions on tobacco availability to minors

• Restrictions on smoking in public places including schools

• Increased taxation

17. Adult Cessation Strategies

Contingency contracting (wards for abstinence)

Social support (from clinician, group, family, friends)

Relaxation techniques (progressive relaxation, deep breathing)

Stimulus control and cue extinction (restricting where smoking takes place)

Coping skills

Reduced smoking and nicotine fading (gradual reduction)

Multicomponent treatment programs

Hypnosis

Acupuncture

Self-help (written materials, videos, tapes, hotlines, helplines)

Computer-tailored messages

18. Time-to-Benefit of Smoking Cessation After Last Cigarette Within 20 minutes: BP decreases; body temperature, pulse rate returns to normal Within 24 hours: Risk of MI decreases Within 1 year: Excess risk for CHD is half that of a person who smokes At 5 years: Stroke risk is reduced to that of someone who has never smoked Within 15 years: CHD risk is the same as a person who has never smoked American Lung Association. www.lungusa.org/tobacco/quit_ben.html 19. Counseling: 5 As Ask: Systematically identify all tobacco-users at every visit Advise: Strongly urge all smokers to quit Attempt: Identify smokers willing to try and quit Assist: Aid the patient in quitting Arrange: Schedule follow-up contact 20. EFFICACY OF SMOKING CESSATION INTERVENTIONS (1 YEAR QUIT RATES) ACUPUNCTURE ---- HYPNOSIS ---- PHYSICIAN ADVICE 6% SELF-HELP METHODS 14% NICOTINE PATCH 11-15% PHYSICIAN ADVICE/SELF-HELP PAMPHLETS 22% AVERSIVE SMOKING (RAPID PUFFING) 25% PHARMACOTHERAPY/BEHAVIORAL THERAPY 25% BEHAVIORAL STRATEGIES (GROUP PROG.) 40% 21. Tailored vs. generic behavioural support material % Abstinent at 4 months Self-help materials tailored for the needs of individual smokers are more effective than standard materials Strecher VJ. Patient Educ Couns. 1999; 36: 107-117. Strecher VJ, et al. Journal of Family Practice. 1994; 39(3): 262270. 22. Pharmacologic Treatment Options POTENTIAL RISKS TREATMENT Slight risk of seizure, contraindicated in those with eating or seizure disorders Zyban (bupropion hydrochloride) May cause mouth or throat irritation Nicotine inhaler Nose and eye irritation, usually disappears within 1 week Nicotine nasal spray Mouth soreness, hiccups, dyspepsia, jaw ache Nicotine polacrilex (nicotine gum) Skin rashes and irritation Nicotine patch 23. Nicotine Replacement Therapy Potent psychoactive drug that induces euphoria Effects are related to blood concentration and the rate of increase in concentration Safe in patients with cardiovascular disease Should be used as part of smoking cessation therapy; however, many individuals may quit without it 24. Smoking and Nicotine

Other toxins in tobacco smoke, not nicotine, are responsible for majority of adverse health effects

• >4000 different chemicals

• • Tar, carbon monoxide, irritants, and oxidant gases

• >40 carcinogens

The main adverse effect of nicotine from tobacco is addiction, which sustains tobacco use

Nicotine dependence leads to continued exposure to toxins in tobacco smoke

Smith et al. Food Chem Toxicol. 1997;35:110730. Hoffman and Hoffman. J Toxicol Environ Health. 1997;50:30764. Benowitz NL. Nicotine Safety and Toxicity . New York: Oxford University Press, 1998. 25. Nicotine Replacement Therapy (NRT) Goal: Attenuate symptoms related to nicotine withdrawal Dysphoric or depressed mood Insomnia Irritability, frustration, or anger Anxiety Difficulty concentrating Restlessness Decreased heart rate Increased appetite or weight gain 26. NRT: Treatment Options Forms of NRT: Gum, Patch, Inhaler, Lozenge, Nasal spray, Sublingual tablet All forms of NRT appear to be similarly effective NRT choice may be based on susceptibility to side effects, patient preference, and availability Little research on combinations of different types of NRT Limited evidence that adding another form of NRT to the nicotine patch increases the success rate 27. Plasma nicotine concentrations for smoking and NRT Minutes Increase in nicotine concentration ( ng/ml ) Cigarette Gum 4 mg Gum 2 mg Inhaler Nasal spray Patch 5 10 15 20 25 30 0 2 4 6 8 10 12 14 Balfour DJ and Fagerstrm KO. Pharmacol Ther . 1996;72:51-81. 28. NRT: Benefit of Behavioral Support West R, McNeill A and Raw M. Thorax. 2000;55:987-999. Silagy C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2002; 1. Limited Support Intensive Support 29. Safety of NRT

NRT is safe in most individuals with cardiovascular disease, even with concomitant smoking

There is a negligible risk of cancer compared to the risk from continued smoking

Although it is a potential fetal teratogen, the benefits outweigh the risks of smoking during pregnancy

There is a low risk of abuse

30. Buproprion (Zyban) Sustained release form of the antidepressant Acts by enhancing CNS noradrenergic and dopaminergic function Start 1 week before smoking cessation date 150 mg QD x 3d, then 150 mg BID x 60d Higher doses and longer duration with greater side effects and no clear benefit 31. Buproprion (Zyban) vs. NRT Jorenby DE et al. N Engl J Med. 1999 Mar 4;340(9):685-91 32. Other Therapies: Limited Success Clonidine Nortryptiline (tricyclic antidepressant) Maclobemide (MAO-inhibitor) Buspirone (anxiolytic) Naloxone (opiate antagonist) Naltrexone (opiate antagonist) Amphetamines 33. Reduced risk cigarettes

Includes low tar and light cigarettes, and novel products that deliver nicotine with minimal tobacco combustion

Low tar cigarettes have not be shown to substantially reduce health hazards of smoking but do provide sufficient nicotine to sustain addiction

Some novel products may deliver fewer or lower levels of toxins but some deliver more carbon monoxide.

Smoking cessation medications are most likely safer than any reduced risk cigarette

34. Smokeless tobacco

Snuff or chewing tobacco has been suggested as a potential aid to harm reduction or smoking cessation

Such products known to cause oral cancer

Smokeless tobacco is addictive and not recommended for smoking cessation

35. THE CLINICAL PRACTICE GUIDELINE ON SMOKING WHATS NEW?

• TREATMENT OF TOBACCO MUST BE CONSIDERED A CHRONIC DISEASE

• ALL CLINICIANS SHOULD OFFER AT LEAST A 3 MIN COUNSELING INTERACTION AT EVERY VISIT

• ALL SMOKERS WILLING TO QUIT SHOULD BE OFFERED PHARMACOTHERAPY (EXCEPTIONS: PREGNANT/ BREAST - FEEDING WOMEN, ADOLESCENTS, THOSE WITH MEDICAL CONTRAINDICATIONS, OR < 10 CIGS/DAY)

36. THE CLINICAL PRACTICE GUIDELINE ON SMOKING WHATS NEW?

• CLINICIANS AND HEALTH CARE DELIVERY SYSTEMS MUST IDENTIFY, DOCUMENT, AND TREAT EVERY TOBACCO USER

• INSURERS AND PURCHASERS SHOULD REIMBURSE:

• • a. COUNSELING/PHARMACOTHERAPY FOR

• • PATIENTS

• • b. CLINICIANS WHO PROVIDE TOBACCO

• • DEPENDENCE TREATMENT

37. PERFORMANCE MEASURES FOR SMOKING CESSATION: HOW DO THEY DIFFER?

• AMA - (1) ALL CHRONIC STABLE CORONARY ARTERY DISEASE PTS IDENTIFIED AS SMOKERS DURING THE REPORTING YEAR

• (2) ALL CHRONIC STABLE CORONARY ARTERY DISEASE PTS WHO RECEIVE TOBACCO CESSATION INTERVENTION IN THE REPORTING YEAR

• HCFA - ALL AMI PTS. SMOKING WITHIN ONE YEAR PRIOR TO ADMISSION WHO RECEIVE SMOKING CESSATION ADVICE OR COUNSELING DURING HOSPITALIZATION

38. PERFORMANCE MEASURES FOR SMOKING CESSATION: HOW DO THEY DIFFER?

• NCQA - BY SURVEY ALL CURRENT/RECENT QUITTERS THAT HAD ONE OR MORE VISITS INDICATING THEY RECEIVED ADVICE TO QUIT FROM AN MCO PRACTITIONER

• JCAHO - ALL AMI PATIENTS SMOKING WITHIN THE YEAR PRIOR TO ADMISSION WHO RECEIVE SMOKING CESSATION ADVICE OR COUNSELING DURING HOSPITALIZATION

39. POINT OF ACCESS: THE USE OF HOSPITALS FOR SMOKING CESSATION

30-40 MILLION PEOPLE HOSPITALIZED ANNUALLY

20-30% OF HOSPITALIZED PATIENTS SMOKE

MOST SMOKERS HAVE HAD TO QUIT

GREATER MOTIVATION TO QUIT

OPPORTUNITY FOR COUNSELING

40. GENERAL INTERVENTION METHODS

INHOSPITAL

• RN/MD COUNSELING

• AUDIOVISUAL MATERIALS

• SELF-HELP PAMPHLETS

POSTHOSPITAL

• RN INITIATED PHONE CALLS:

• • WEEKLY X 2-3 WEEKS

• • MONTHLY X 4-6 MONTHS

• NICOTINE REPLACEMENT THERAPY

• 1-2 FACE-TO-FACE VISITS AS NEEDED

41. DISSEMINATION OF STAYING FREE SMOKING CESSATION PROGRAM

PRIMARY AIM

TO DETERMINE EFFECTIVENESS OF INITIAL IMPLEMENTATION INTO SEVERAL HOSPITALS IN SAN FRANCISCO BAY AREA

SECONDARY AIM

TO IMVESTIGATE FACTORS THAT PREDICT SUSTAINABILITY OF STAYING FREE

42. STAYING FREE INTERVENTION

WHAT PATIENTS RECEIVE:

• A STRONG PHYSICIAN MESSAGE ABOUT THE HAZARDS OF SMOKING

• A 17 PAGE WORKBOOK ON QUITTING SMOKING

• A 16 MINUTE VIDEOTAPE SHOWN AT THE BEDSIDE ABOUT HOW TO REMAIN AN EX-SMOKER

• A RELAXATION AUDIOTAPE

43. STAYING FREE INTERVENTION

WHAT PATIENTS RECEIVE:

• A COUNSELING SESSION AT THE BEDSIDE BY A HEALTH CARE PROFESSIONAL

• PHARMACOLOGICAL THERAPY AS NEEDED

• FOLLOW-UP PHONE CALLS FROM HOSPITAL STAFF AND/OR PUBLIC HEALTH (1 TO 4)

• OUTPATIENT REFERRALS TO PUBLIC HEALTH PROGRAMS AND OTHER LOCAL RESOURCES

44. MODEL I: A VA HOSPITAL PALO ALTO HEALTH CARE SYSTEM

SPECIAL FEATURES:

• INTERVENTION PROVIDED BY PSYCHOLOGISTS, PSYCHOLOGY INTERNS AND QUALITY ASSURANCE NURSE

• USE OF CLOSED CIRCUIT TV TO SHOW VIDEO

• USE OF COMPUTERIZED STAYING FREE TEMPLATES TO DOCUMENT INTERVENTION IN PATIENTS ELECTRONIC MEDICAL RECORDS

• STAYING FREE GROUP E-MAIL CREATED TO DISSEMINATE INFORMATION/UPDATES TO TEAM

• ASK ME ABOUT STAYING FREE ID TAGS FOR STAFF

45. MODEL II: A COUNTY HOSPITAL SANTA CLARA VALLEY MEDICAL CENTER

SPECIAL FEATURES:

• INTERVENTION PROVIDED BY PHYSICIANS

• FOLLOW-UP PHONE CALLS PROVIDED BY SANTA CLARA COUNTY PUBLIC HEALTH TOBACCO PREVENTION AND EDUCATION PROGRAM

• SPANISH AND VIETNAMESE LANGUAGE VERSIONS OF STAYING FREE

• CERTIFICATES OF ACHIEVEMENT FOR PATIENTS

46. MODEL III: COMMUNITY HOSPITALS

SPECIAL FEATURES:

• MILLS-PENINSULA HEALTH SERVICES

• • INTERVENTION PROVIDED BY CARDIAC REHABILITATION AND A DIVERSE TEAM OF VOLUNTEERS (NURSING STUDENT, FORMER CARDIAC REHABILITATION PATIENTS, MENDED HEARTS VOLUNTEERS, RETIRED COUNSELORS)

• • DEDICATED STAYING FREE PHONE LINE

• COMMUNITY HOSPITAL OF LOS GATOS

• • INTERVENTION PROVIDED BY STAFF CHAPLAIN

• • COMPUTERIZED IDENTIFICATION OF ALL SMOKERS AT ADMISSION

47. MAKING HOSPITAL-WIDE SYSTEM LEVEL CHANGES THAT SUCCEED

• STEP 1:

• DETERMINE PERCENTAGE OF ALL SMOKERS ENTERING A HOSPITAL WHO SMOKED IN PAST 30 DAYS

• • • ADMISSION SHEETS

• • • FACE TO FACE CONTACT (2-4 WEEKS)

48. MAKING HOSPITAL-WIDE SYSTEM LEVEL CHANGES THAT SUCCEED

• STEP 2:

• ACTIVELY SCREEN ALL SMOKERS

• • UTILIZE COMPUTERIZED ADMISSION FORM

• • INCORPORATE INTO NURSING HISTORIES

• • INTEGRATE AS PART OF STANDING CCU/CSU ADMISSION ORDERS

• • INCORPORATE AS A VITAL SIGN

• • USE PATIENT STICKERS

49. MAKING HOSPITAL-WIDE SYSTEM LEVEL CHANGES THAT SUCCEED

• STEP 3:

• EXPECT ALL HEALTH CARE PROFESSIONALS TO INTERVENE

• • ASK ABOUT SMOKING STATUS APPROPRIATELY

• • OFFER MOTIVATIONAL INTERVIEW

• • DOCUMENT, DOCUMENT, DOCUMENT (TRACKING FORM, PROGRESS NOTES)

50. MAKING HOSPITAL-WIDE SYSTEM LEVEL CHANGES THAT SUCCEED

• STEP 4:

• TRAIN ALL MDs TO RESPOND

• • ASK ABOUT SMOKING STATUS APPROPRIATELY

• • OFFER STRONG, CREDIBLE MESSAGE ABOUT QUITTING

• • DETERMINE NEED FOR PHARMACOLOGICAL THERAPY

• • DOCUMENT, DOCUMENT, DOCUMENT (MEDICAL RECORD, TRACKING FORM)

51. MAKING HOSPITAL-WIDE SYSTEM LEVEL CHANGES THAT SUCCEED

• STEP 5:

• CONSIDER A SYSTEM TO OFFER SELF-HELP MATERIALS AND BEHAVIORAL COUNSELING

• • STANDARDIZE PATIENT EDUCATION MATERIALS

• • UTILIZE CLOSED-CIRCUIT TELEVISION FOR VIDEOTAPES

• • DETERMINE WHO CAN BE TRAINED TO PROVIDE BEHAVIORAL COUNSELING (ie. VOLUNTEERS, CANDIDATE MEDICAL STUDENTS, CHAPLAINS, NURSES, PSYCHOLOGISTS)

• • PROVIDE A LIST OF COMMUNITY RESOURCES

52. MAKING HOSPITAL-WIDE SYSTEM LEVEL CHANGES THAT SUCCEED

• STEP 6:

• DETERMINE A MECHANISM FOR FOLLOW-UP

• • USE SMOKING INTERVENTIONISTS TO UNDERTAKE PATIENT FOLLOW-UP

• • OFFER TELEPHONE CONTACT BY HEALTH CARE PROFESSIONALS ALREADY MAKING CALLS

• • INTEGRATE CALLS WITHIN PUBLIC HEALTH DEPT.

• • USE CENTRALIZED TELEPHONE SYSTEM FOR ALL SMOKERS WITHIN COMMUNITY

• • DOCUMENT, DOCUMENT, DOCUMENT

53. Clinicians Guide, Agency for Health Care Policy and Research 54. Quit Smoking Action Plan, American Lung Association