isptid 2010 pres address dr kinnunen; women & smoking
TRANSCRIPT
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Taru Hannele Kinnunen, PhDHarvard Medical School
Harvard School Dental Medicine
Department of Oral Health Policy and Epidemiology
Women and Tobacco Use: Global Challenge
The 8th Conference of the International Society for The Prevention of Tobacco Induced Diseases
Presidential Address, September 29, 2010
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Overview and Observations
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Per Capita Cigarette Consumption United States: 1880-2000
Source: Tobacco Situation and Outlook Report, U.S. Department of Agriculture, U.S. Census
Note: Among persons >18 years old.
0
2
4
6
8
10
12
1880
1885
1890
1895
1900
1905
1910
1915
1920
1925
1930
1935
1940
1945
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
YEAR
PO
UN
DS
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Young Women and Tobacco Use
• decline in smoking rates among adult women stalled while smoking rates rose steeply among teenaged girls
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Example: Tobacco Use in Finland
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The Opponent in the Challenge
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• light cigarettes are less harmful than regular cigarettes
• smoking cigarettes helps staying slim
Marketing
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Smoking-related illnesses such as lung cancer and cardiovascular disease are becoming more more
prevalent among women
Concern 1
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Cancer Death Rates by Site: Women
0
10
20
30
40
50
60
70
80
1930 1940 1950 1960 1970 1980 1990
Uterus
Breast
Pancreas
Liver
Ovary
Stomach
Lung
Colo-rectal
Source: American Cancer Society, 1999
Rates are adjusted to the 1970 census population
Rate
per
100,0
00 f
em
ale
po
pu
lati
on
Year
United States, 1930-1995
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Smoking-Related Diseases Epidemic among Women
" When calling attention to public health problems, we must not misuse the word ‘epidemic.’ But there is no better word to describe the 600 % increasesince 1950 in women’s death rates for lung cancer, a disease primarily caused by cigarette smoking. Clearly, smoking-related disease among women is a full-blown epidemic.“
David Satcher, M.D., Ph.D.
Surgeon General
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Concern 2
• despite the fact that women smoke at lower rates than men, their disease risk associated with smoking is higher, and present even with minimal tobacco use
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RR of Myocardial Infarction by Tobacco Exposure and Gender
0
0.5
1
1.5
2
2.5
3
3.5
risk
adj.
never ex-
smoker
non-inh. 1-14
g/day
15-24
g/day
> 24
g/day
men womenPrescott et al., 1998, BMJ
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PlaqueRuptureThrombosisInfarction
PlaqueIshemia
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reduced plasma concentration of
ESTROGEN
ENDOTHELIAL DYSFUNCTION
CHRONIC SMOKING
LIPID ABNORMALITIES
reduced plasma concentration of
ESTROGEN
THROMBOSIS
ATHEROSCLEROTICPLAQUE
FORMATION
PLAQUE INSTABILITY,
RUPTURE
CHRONIC EVENTS,stable angina
ACUTE EVENTS,unstable anginamyocardial infarctionsudden death
NO
platelet aggregationfibrinogenblood viscosity
LDL HDL
Effects of Tobacco and Estrogen on Atherosclerosis
Bolego et al., Cardiovasc Res2002, 53:568-76
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The Global Challenge
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Concern 3• smoking may increase women’s
vulnerability to gender-specific health consequences such as osteoporosis and reproductive issues
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Breast Cancer
• Until recently it was thought that tobacco use contributed very little for breast cancer
• However, it was recently shown that– Current smoking increased breast cancer
risk particularly among those without familial risk
– Smoking during developing years increased the risk
Reynolds et al., 2004 J Natl Cancer Inst
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Reproductive Health
• Increased risk for conception delay infertility.
• Pregnancy complications, premature birth, low-birth-weight infants, stillbirth, and infant mortality.
• Increased risk for ectopic pregnancyand spontaneous abortion.
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Reproductive Health cont.
• Biochemical changes in fetus (nAChR)
• Developmental consequences from maternal smoking of the offspring
• Menopause at a younger age than do nonsmokers, and more severe menopausal symptoms
• Oral contraceptives and tobacco use increase CVD risk
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Second Hand Smoke (ETS) and Mortality
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ETS and Lung Cancer
• Dana Reeve dies of lungcancer at 44
• Widow carried on activismafter Christopher Reeve'sdeath
•Dana Reeve, seen at a 2004 event, revealed that she had lung cancer,
• She was a nonsmoker.
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Concern 4
• Quitting smoking may be harder for women
Osler et al., 1999, Prev. Med, Perkins 2002, Drugs
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Clinical Guidelines for TX
Intensity: Dose-response
Type: Individual/Group/Telephone
Content• Problem solving/Skills training• Intra-treatment social support• Extra-treatment social support
First-line therapies:• NRT (gum, patch, lozenge,
inhlaler, spray, microtab)• Bupropion(Zyban, Wellbutrin)• Varenicline (Champix, Chantix)
• Second-line therapies:• nortriptyline• clonidine
Combination therapies• NRT+NRT• Bupropion SR + NRT• Varenicline + ?
CounselingBehavioral Tx
Pharmacological Tx
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Quitting Smoking May Be…
• Nicotine replacement therapy may not be as effective for women.
Osler et al., 1999, Prev. Med, Perkins 2002, Drugs
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Quitting Smoking May Be…
• Women more fearful of gaining weight.
• Menstrual cycle
• Depression and smoking cessation
• Lower education and SES
Osler et al., 1999, Prev. Med, Perkins 2002, Drugs
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Tobacco Dependence Treatment for Women In General
• Search for barriers to cessation and reduce them
– Weight concerns– Child care– Social support– Etc. etc. etc.
• Educate – globally/locally• Community approach• Map and intervene on other risk factors
– lipids, insulin resistance, weight etc. etc.
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Exercise ?
• regular exercise improves mood, reduces stress and cigarette cravings, as well as reduces fear of weight gain associated with smoking cessation exercise may be an especially promising treatment for women who want to quit smoking
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The Global Challenge
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Thank You!
Funding:NIDANCINIDCRStudyStaffGum+StopStepElderScreeningStudy