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1

Tobacco Dependencyin Women

the Reproductive Years

Jorge J. Garcia MDClinical Assistant Professor

Department of Obstetrics and GynecologyUniversity of Miami

Miller School of Medicine

Disclaimer

I have no financial relationship with anypharmaceutical company

I have no financial relationship with any companyinvolved in the production, advertisement ,distribution, or sale of any tobacco products

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2

Acknowledgement

This presentation is made possible through thesupport of:

South Florida Area Health Education Center

University of Miami Miller School of Medicine

Department of Family Medicine

Department of Obstetrics and Gynecology

Learning Objectives

Upon completion of this continuing educationactivity, participants will be able to:

Understand the global tobacco epidemic

Describe the risks associated with the use of tobaccoproducts particularly in the context of pregnancy

Employ evidence-based guidelines for smokingcessation during pregnancy

Recognize when to use pharmacologic intervention

Establish a smoking cessation program in thepractice setting

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Tobacco Use Is One Of TheBiggest Public Health ThreatsThe World Has Ever Faced

Almost half of the world's children breathe airpolluted by tobacco smoke.

Tobacco use kills 5.4 million people a year - anaverage of one person every six seconds - andaccounts for one in 10 adult deaths worldwide.

It is a risk factor for six of the eight leading causes ofdeaths in the world.

Global Causes of Death

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Dea

ths

inM

illio

ns

TobaccoLower Respiratory Infections*

Diarrheal Diseases*

Perinatal Conditions*

TuberculosisAIDS

* WHO World Health Report 2002

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4

1010

Currently:Currently: 4.9 million people die4.9 million people die

per yearper year 13,400 people per day13,400 people per day 560 people every hour560 people every hourBy 2030:By 2030: 10 million people a10 million people a

year will die fromyear will die fromtobacco usetobacco use

70% of those deaths70% of those deathswill occur inwill occur indeveloping countriesdeveloping countries

Global DeathsGlobal Deaths

4.9

10

0

1

2

3

4

5

6

7

8

2000 2030

mill

ions

ofde

aths

Developed CountriesDeveloping Countries

NY TIMES, 2/24/08

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5

Current Smoking Among Adults by State, 2005

•The percentage of all adults in each state/area who reported having smoked >100 cigarettes during their lifetimesand who currently smoke every day or some days.•Source: BRFSS, 2005.

Cigarette Smoking in FL

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6

Current Use of Various Tobacco Productsamong Adults, by Sex—United States, 2000

31.3

25.7

4.5

1.02.5 2.5

0.1

21.3 21.0

0.2 0.1 0.2 0.1 0.10

5

10

15

20

25

30

35

Any Use Cigarettes Cigars Pipes Snuff ChewingTobacco

Bidis

Per

cen

t

MalesFemales

Note: Current users report using either every day or on some daysSource: National Center for Health Statistics

Per-Capita Consumption of DifferentForms of Tobacco in The U.S. 1880-2005

Cigarettes

Cigars

Pipe/rollyour own

Chewing

Snuff

0

2

4

6

8

10

12

14

1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000Year

Po

un

ds

of

To

bac

coP

er-C

apit

a

Source: Tobacco Situation and Outlook Report, U.S. Department of Agriculture, U.S. CensusNote: Among persons >18 years old. Beginning in 1982, fine-cut chewing tobacco was reclassified as snuff.

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7

2020

MenMen

Women

0

10

20

30

40

50

60

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

YEAR

%C

UR

RE

NT

SMO

KE

RS

Trends in cigarette smoking* among adults aged>18 years, by sex - United States, 1955-2004

Source: 1955 Current Population Survey; 1965-2004 National Health Interview Surveys.

*Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes and whocurrently smoked. Since 1992, current smokers were defined as persons who reported having smoked >100cigarettes during their lifetime and who reported now smoking every day day or some days.

23.4%

18.5%

0

10

20

30

40

50

60

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000Year

Per

cen

t

Cigarette Smoking* Among Adults byGender—United States, 1955-2004

Source: 1955 Current Population Survey; 1965-2002 NHIS*Estimates since 1992 include some-day smoking

Males

Females

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8

Adult Per Capita Cigarette Consumption and MajorSmoking-and-Health Events—United States, 1900-2005

0

1,000

2,000

3,000

4,000

5,000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

Nu

mb

ero

fCig

aret

tes

Source: USDA Tobacco & Situation Outlook report, 2005 ;1986-2000 Surgeon General's Reports

Great Depression

1st SurgeonGeneral’s Report

Fairness DoctrineMessages on TVand Radio

Federal CigaretteTax Doubles

MasterSettlementAgreement

1st Smoking-Cancer Concern

The good news is…most smokers want to quit

90% regret ever having started to smoke

89% plan to quit; only 3% don’t want to quit

89% believe health will improve if quit

84% have tried to quit in the past

27% try to quit each year…

2004/2005 Assessing Hard Core Smoking Survey of US smokers ages 25+ years (n = 1,000)

2424

0

10

20

30

40

50

60

1965

1967

1969

1971

1973

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

Year

Per

cent

Percentage of Ever Smokers* Who Have Quit, AdultsAged > 18 Years, by Sex-United States, 1965 - 2004

Source: National Health Interview Surveys, 1965-2004;Centers for Disease Control and Prevention: National Center for Health Statistics and Office on Smoking and

Health.*Ever-smoked >100 cigarettes,Also known as the quit ratio. Note: estimates since 1992 incorporate same-day smoking

Men

Women

51.4%

49.7%

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9

0

10

20

30

40

50

60

70

1978-1980

1983-1985

1987-1988

1990-1991

1992-1993

1994-1995

1997-1998

1999-2000

2001-2002

2003-2004

Year

Per

cen

t

Current Cigarette Smoking byRace/Ethnicity—United States, 1978-2004

Source: National Health Interview Surveys, 1978-2004, selected years, aggregate data

White

AfricanAmerican

Hispanic

Asian

AmericanIndian

30.4

23.122.8 21.3 19.2

0

10

20

30

40

50

60

Per

cen

t

Current Cigarette Smoking: Hispanic/LatinoAdults, 1999-2001

Source: National Survey on Drug Use and Health, 1999-2001

Puerto Rican Mexican Central orSouth American

Cuban Overall

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10

Average Age First Cigarette Use byRace/Ethnicity, 1999-2001

Source: National Survey on Drug Use and Health, 1999-2001.Rate is the number of persons in the age group who initiate (first use) use of the drug in specified year

14.8 15.5 15.7 15.9 16.1 16.4 16.6 17.118.8

02468

1012141618202224

AmericanIndian/

Alaska Native

White Hawaiian Mexican Korean AfricanAmerican

PuertoRican

Chinese AsianIndian

Ag

ein

Yea

rs

Cigarette Smoking by Education, Ages 25+—United States, 1966-2004

Source: 1966-2004 National Health Interview Surveys*Estimates since 1992 incorporate some-day smoking

0

10

20

30

40

50

60

1966 1969 1972 1975 1978 1981 1984 1987 1990 1993 1997 2000 2003Education (yrs)

%C

urr

ent

smo

kers

<12 12 13-15 16+

Current Cigarette Smoking: GLBT Adults

Sources:

Ryan, et al - Am J Prev Med, 2001:21(2): 142-149

Tang, et al – Cancer Causes & Control, 2004, Oct 15(8):797-803

Dilley et al – Letter to editor, Cancer Causes & Control, 2005, Nov 16(9):1133-4

Prevalence ranged from 25 – 50 % in gay and bisexualmen

Prevalence ranged from 11- 50% in lesbian andbisexual women

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SMOKING AMONG CHILDRENAND ADOLESCENTS

Current Cigarette Smoking* by Grade in School—United States, 1975-2006

Source: Institute for Social Research, University of Michigan, Monitoring the Future Project, 2005*Smoking 1 or more cigarettes during the previous 30 days

0

5

10

15

20

25

30

35

40

45

1975197719791981198319851987198919911993199519971999200120032005

Year

Per

cen

t

12th Grade 10th Grade 8th Grade

21.6

14.5

8.7

Current Cigarette Smoking* among 12th Gradersby Race—United States, 1977-2006

05

1015

2025

3035

4045

50

1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005Year

Per

cen

t

White Black Hispanic

Source: Institute for Social Research, University of Michigan, Monitoring the Future Project, 2005*Smoking 1 or more cigarettes during the previous 30 days

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Current Cigarette Smoking among Youth: GLBT

Source: Ryan, et al - Am J Prev Med, 2001:21(2): 142-149

38% for youth with same gender sexual experience

59% for students who self-identified as lesbian, gayand bisexual youth

Current* Tobacco Use† Among Middle and HighSchool Students, 2004

13.39.8

63.5 3.5 2.4 2

28.2

22.5

11.6

5.93.2 2.6 2.7

0

10

20

30

40

50

Any Use Cigarettes Cigars Smokeless Pipes Bidis Kreteks

Per

cen

t

Middle SchoolHigh School

* Used tobacco on ≥ 1 of the 30 days preceding the survey† Use of cigarettes, smokeless, cigars, pipes, Bidis, or KreteksSource: National Youth Tobacco Survey, 2004

†

0

40

80

120

160

1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003

Year

Initi

ates

/1,0

00n

ever

smo

kers

Incidence of Initiation of Any Cigarette Use—United States, 1965 -2003

1 The numerator of each rate is the number of persons in the age group who initiated use of the drug in the specified year,while the denominator is the person-time exposure of persons in the age group measured in thousands of years..

2 Estimated using 2003 and 2004 data only. 3 Estimated using 2004 data only.3 Estimated using 2004 data onlySource: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2002, 2003, and 2004..

12 to 17

18 to 25

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Initiation Rates among White Males by BirthCohorts, by Age—United States, 1900-1975

0123456789

101112131415

5 10 15 20 25 30 35

1900 1910 1920 1930 1940 1950 1960 1970 1975

Per

cen

t

Age

INFLUENCES ON TOBACCO USE AMONGRACIAL/ETHNIC GROUPS

Smoking Patterns among African Americans

African Americans tend to start smoking later andsmoke fewer per day

Most likely to smoke higher tar and nicotine brands

Most likely to smoke mentholated cigarettes

Higher serum cotinine levels

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Socio-cultural Factors Influencing SmokingRates among Native Americans

Important to distinguish between sacred uses andaddictive use

Reliance on revenue from tobacco sales (reservationstax exempt, internet sales)

Smoking prevalence seems to vary less by SES inNative Americans than other groups

Socio-cultural Factors Influencing SmokingRates among Asian and Pacific Islanders

Age

Gender

Place of birth

Level of acculturation

Socio-cultural Factors Influencing SmokingRates among Hispanics

Country of origin

Level of acculturation

English speaking

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Socio-cultural Factors Influencing SmokingRates among GLBT Populations

Daily stress due to homophobia

Important social focus on places where smokingis prevalent (bars)

Alcohol and drug use may be higher

Tobacco industry targeting

Contact info:

Mike Boysun

Phone number: 360-236-3671

Email: mike.boysun@doh.wa.gov

Thanks! Questions??

Mike Boysun

Epidemiologist and Evaluation Coordinator

Tobacco Prevention and Control Program

Washington State Department of Health

Slides adapted from presentation by:

Tobacco Use in the United States

April, 2007

Corinne G. Husten, MD, MPHCDC, OSH

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Current Cigarette Smoking by Race/Ethnicity—United States, 2003-2004

20.8

36.3

11.515.7

22.4

0

10

20

30

40

50

Per

cen

t

Source: National Health Interview Surveys, 2003 and 2004, aggregate data

White

AfricanAmerican

Hispanic

Asian

AmericanIndian

1982 SURGEON GENERAL’SREPORT

“Cigarette smoking is themajor single cause of cancermortality in the UnitedStates”

Cigarettes kill moreAmericans than alcohol,car accidents, suicide,AIDS, homicide andillegal drugs combined

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All Tobacco Is Toxic!All Tobacco Is Toxic!

4000 chemicals in a cigarette

Tar & toxins – black & sticky

CO burns and displaces oxygen throughout the body

Burning process breaks up the toxins

Toxins heat up & release gases

When you draw on the cigarette it passes these gasesinto the lungs

Heart works harder, devastates the cilia

Carbon Monoxide & Your BloodCarbon Monoxide & Your Blood

CO is a colorless, odorless, tasteless gas that is partof the air we breathe

Many sources of carbon monoxide such asincinerators, car exhaust fumes and gas furnaces

When the level of CO in your body increases, theability of your blood to carry oxygen is decreased

Smoking increases the amount of CO in your blood

Adverse Health Effects of Smoking

Cancers

– Lung

– Laryngeal, pharyngeal, oralcavity, esophagus

– Pancreatic

– Bladder and kidney

– Cervical and endometrial

– Gastric

– Acute myeloid leukemia

Reduced fertility in women, poorpregnancy outcomes, low birth weightbabies, sudden infant death syndrome

Cardiovascular diseases

– Coronary heart disease

– Stroke

– Abdominal aortic aneurysm

Respiratory diseases

– Acute respiratory illnesses, e.g.,pneumonia, otitis media, asthma

– Chronic respiratory diseases (COPD)

Cataract

Periodontitis

Diabetes (2-fold increased incidence)

– (Diabetes Care 28:10 Oct 2005)

U.S. Department of Health and Human Services. The Health Consequences of Smoking:A Report of the Surgeon General, 2004.

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Smoking increases the risk for many types ofcancer:– Lip

– Mouth

– Bladder

– Kidney

– Esophagus

– Lung

– Larynx (voice box)

– Pancreas

– causes coronary heartdisease

– doubles risk for stroke

– can cause chronic diseases:

• bronchitis

• COPD

• asthma

• high blood pressure

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Environmental Tobacco Smoke (ETS)

Second-hand tobacco smoke is dangerous to health.

It causes cancer, heart disease and many other seriousdiseases in adults.

Almost half of the world's children breathe air polluted bytobacco smoke, which worsens their asthma conditions andcauses dangerous diseases.

At least 200 000 workers die every year due to exposure tosecond-hand smoke at work.

More About Tobacco Use

Tobacco use causes more premature deaths in the United States than any otherpreventable risk.

If current patterns of smoking behaviors continue, an estimated 6.4 million of today'schildren can be expected to die prematurely from smoking-related illnesses.

Cigarette smoking increases coughing, shortness of breath, and respiratory illnesses;decreases physical fitness; and adversely affects blood cholesterol levels.

Smoking cigars increases the risk of oral, laryngeal, esophageal, and lung cancers. Smokeless tobacco is not a safe alternative to cigarettes. Using it causes cancers of the

mouth, pharynx, and esophagus; gum recession; and an increased risk for heartdisease and stroke.

Light cigarettes are not healthier than regular cigarettes. Secondhand smoke puts children in danger of developing severe respiratory diseases

and can hinder the growth of their lungs. Exposure to secondhand smoke as a child or adolescent may increase the risk of

developing lung cancer as an adult,7 or worsen existing asthma. Tobacco use causes stained teeth, bad breath, and foul-smelling hair and clothes.

The Dollars in the US

Direct Medical Costs $260 millionLost productivity due to death $270 million

Average US smoker spends per yearon cigarettes

$1600

Tobacco industry spending onmarketing and promotion

$13.4 billion (2005)

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Major Sources of Data on TobaccoUse in the United States

Consumption Data— U.S. Department of Agriculture (USDA)

Surveys of Adults— National Health Interview Survey (NHIS)— National Survey on Drug Use and Health (NSDUH)— National Health and Nutrition Examination Survey

(NHANES)— Behavioral Risk Factor Surveillance System (BRFSS)— Current Population Survey (CPS)— Adult Tobacco Survey (ATS)

Major Sources of Data on Tobacco Usein the United States

Surveys of Youth— Monitoring the Future Surveys (MTFS)— Youth Risk Behavior Surveillance System (YRBSS)— National Survey on Drug Use and Health

(NSDUH)— National Health and Nutrition Examination Survey

(NHANES)— Teenage Attitudes and Practices Surveys (TAPS)— National Youth Tobacco Survey (NYTS)— Youth Tobacco Survey (YTS)

National Health Interview Survey (NHIS)

Current Population Survey (CPS)

National Survey on Drug Use and Health (NSDUH)

Monitoring the Future Survey (MTFS)

Youth Risk Behavior Survey (YRBS)

National Youth Tobacco Survey (NYTS)

Birth Certificate Vital Statistics

National Surveys

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Behavioral Risk Factor Surveillance System(BRFSS)

Current Population Survey (CPS)

Youth Tobacco Survey (YTS)

Pregnancy Risk Assessment Monitoring System(PRAMS)

Adult Tobacco Survey (ATS)

Vital Statistics (birth, death)

State-specific Surveys

U.S. Output of Fine Cut Tobacco andSnuff, 1950-2005

0

10

20

30

40

50

60

70

80

90

100

1950 1954 1958 1962 1966 1970 1974 1978 1982 1986 1990 1994 1998 2002

Mill

ion

po

un

ds

Source: USDA Tobacco & Situation Outlook report, 2005 ;1986-2000 Surgeon General's Reports

0

2

4

6

8

10

12

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

Year

Bill

ion

s

Total consumption

Large cigarsand cigarillos

Small cigars

Ban Advertising of Little Cigars

SGR

Cigar Aficionado

Begin advertisinglittle cigars

U.S. Output of Small and Large Cigars,1950 to 2005

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Prevalence of Smoking among White Males byBirth Cohorts, by Age—United States, 1900-1980

0

10

20

30

40

50

60

70

80

5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80

1900 1910 1920 1930 1940 1950 1960 1970 1980

Per

cen

t

Sources: National Center for Health Statistics, public use data tapes, 1978-1980, 1987; Burns et al. 1997.

Age

Prevalence of Smoking among White Females byBirth Cohorts, by Age—United States, 1900-1980

Sources: National Center for Health Statistics, public use data tapes, 1978-1980, 1987; Burns et al. 1997.

0

10

20

30

40

50

60

70

80

5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80

1900 1910 1920 1930 1940 1950 1960 1970 1980

Per

cen

t

Age

Get with the guidelines

David Brown, MDDavid Brown, MDFamily Medicine & Community HealthFamily Medicine & Community Health

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5TOBACCOHISTORY

WHY DO WESMOKE?

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Addiction Facts

Cigarette addiction is a 3-partPhenomenon

Physical addiction – as evidenced by thebiochemical changes in the brain

Physiological addiction- becoming reliant on it todo for “us” what we think we can’t, and use it tobus us time and distract others from us

Habit- smoke 60% of our cigarettes because of anenvironmental or behavior trigger

RJR - Winston

USA

Working Class Women are target of mass marketingcampaigns by tobacco companies

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Carrie Nation (WCTU founder) - 1890s

These tobacco users transmit nervousdiseases, epilepsy, weakenedconstitutions, depraved appetites anddeformities of all kinds to theiroffspring.

The tobacco user can never be thefather of a healthy child.

ETSexposure!

”Smoking behaviour of women differs from that ofmen…more highly motivated to smoke…they find itharder to stop smoking…women are more neuroticthan men…there may be a case for launching afemale oriented cigarette with relatively highdeliveries of nicotine”

1976 Research Report

British American Tobacco

Recruiting Women Smokers - the Origin of the Problem

1932 - mustbe good foryour health!

1942 - it’spatriotic to

smoke!

1929 - avoidgetting fat

1926 - don’tbe left out!

1934 - curesdepression and

tiredness!

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Targeting Women — Taking Aim at MinoritiesCurrent Ads in Women’s Magazines

Prince: Caines

Czech Republic

The TobaccoIndustry DOESmarket to women

PM: L & M

Czech Republic

There areapprox. 250million womenaddicted totobaccoworldwide

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“Selling tobacco products to womencurrently represents the singlelargest product marketingopportunity in the world.”

Kaufman and Nichter 2001

Altadis: Gauloise

England & Qatar

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B&W - Lucky Strike

Czech Republic

Tobacco companies havenot produced a range ofbrands aimed at women.Most notable are the”women-only” brands:those feminised cigarettesare long, extra slim, lowtar, light coloured ormenthol.

ManhattanPeru

Women’s tobacco use is aninternational issue with complexdimensions and implications

www.trinketsandtrash.org

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http://roswell.tobaccodocuments.org/bar_promos/camel_promo1/index.htm

www.trinketsandtrash.org

“Superslim Caprimeans less smoke forthose around you”

“Blow somemy way”

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PM - ChesterfieldUSA - 1949

The tobaccoindustry has yearsof advertisingexperience – and abig budget

6 TOBACCOADDICTIONHABIT

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TOBACCO: FRIEND OR FOE?TOBACCO: FRIEND OR FOE?

Effects of Tobacco on Health

All Tobacco is Toxic!

Carbon Monoxide and Your Blood

Pharmacological Treatments

Quit Tobacco in the House

and in the Car

Preparing for Quit Day

One Dozen Decisions

Effects Of Tobacco on HealthEffects Of Tobacco on Health

Every day, people suffer from illnesses caused bythe effects of their smoking or from exposure tosecond-hand or environmental tobacco smoke.

Avoiding TriggersAvoiding TriggersWhat are the events or activitiesthat trigger you to smoke?

Review possible triggers andpossible solutions on pages 52-53

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H A L TH A L T

Feelings of hunger, anger, loneliness andfatigue may serve as triggers to returnto smoking/tobacco use

Two-thirds (67%) of people return tosmoking when they experience anyof the above feelings for longperiods of time

Nutrition and ExerciseNutrition and Exercise Research studies show that the nicotine in cigarettes

is responsible for increasing your metabolic rate

Due to the higher metabolic rate when smoking, theex-smoker now has a lower metabolic rate and burns100 to 200 fewer daily calories

Nicotine can serve as an appetite suppressant—manypeople rely on that fact to keep their weight down.

TOBACCOand

PREGNANCY

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SMOKING DURING PREGNANCY

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Cigarette Smoking During Pregnancy—United States, 1989-2004

0

5

10

15

20

25

1989 1991 1993 1995 1997 1999 2000 2002 2003 2004

Per

cen

t

Note: Percentage excludes live births for mothers with unknown smoking status.Sources: National Center for Health Statistics 1992, 1994; Ventura et al. 1995, 1997, 1999, 2000; Martin et al. 2002, 2003.

20

10.2

Prevalence of Smoking During Pregnancy, PRAMS

Prevalence of Smoking Before and During Pregnancy, PRAMS2001-2004

21.8

19.7 19.521.3

9.89.4 10.010.6

0

5

10

15

20

25

2001 2002 2003 2004

Per

cent

Before During

Source:Source: Florida’s Increasing Prevalence of Smoking During Pregnancy: TheImpact of Revising the Birth Certificate ,Angel Watson, MPH, RHIA, Florida,Angel Watson, MPH, RHIA, FloridaDepartment of HealthDepartment of Health

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Multiple Determinants ofChildren’s Health

Genetic

Social

Environmental

Disease conditions

Medical care

Health Systems

Politics/Economics

Tobacco and Child Health

Smoking impacts children through:prenatal exposureenvironmental tobacco smoketeen smoking

Direct medical cost of all pediatric diseaseattributable to parental smoking-$7.9 billion dollars

$13.76 billion in loss of life 15% reduction in parental smoking could save

$1 billion in direct medical costsCDC-1999

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Smoking Harms Every Phase of Reproduction*

Before Pregnancy, women who smoke

have more difficulty becoming pregnant and

have a higher risk of never becoming pregnant.

Source: Centers for Disease Controlhttp://www.cdc.gov/tobacco/sgr/sgr_2004/consumerpiece/page5.htm

Smoking Harms Every Phase of Reproduction

During pregnancy, nicotine freely crossesthe placenta and has been found inamniotic fluid and the umbilical cord bloodof newborn infants. (It is found in breastmilk too.)

Source: American Cancer Societyhttp://www.cancer.org/docroot/PED/content/PED_10_2x_Smokeless_Tobacco_and_Cancer.asp?sitearea=PED

Maternal smoking associations:

– Effects during Pregnancy

• Low Birth Weight (growth retardation)

– Effects in Infancy

• Increased SIDS

– Effects in Childhood and Adolescence

• Increased hyperactivity (ADHD)

• Increased alcohol & drug use as adolescent

• Decreased child IQ

• Increased asthma

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Smokers are more likely than nonsmokers to have a miscarriage orectopic pregnancy.

Babies born to smokers are 1.5–3.5 times more likely to have low birthweight

Low-birth weight babies are at risk for serious health problemsthroughout their lives.

Up to ¼ of low birth weight births could be prevented by eliminatingsmoking during pregnancy.

Up to 8% of all babies who die less than a week after birth do sobecause of problems caused by their mothers’ smoking duringpregnancy.

The risk for sudden infant death syndrome (SIDS) increases three-foldfor mothers who smoke during and after pregnancy and two-fold formothers who smoke only after delivery.

Smoking during pregnancy increases the risk of stillbirth by 40 to 60percent.

SMOKING DURING PREGNANCY

THE SINGLE MOST PREVENTABLE CAUSE OF ILLNESS ANDDEATH IN MOTHERS AND INFANTS

Smoking during Pregnancy

Higher risk of gestational diabetes

5 to 6 % of perinatal deaths

7 to 10 percent of preterm deliveries

Asthma - 25% higher rate in children whose mothersmoked less than 10 cigarettes per day

– 36% higher in children whose mothers smokedmore than 10 cigarettes per day.

Smoking during Pregnancy

Tobacco Use During Pregnancy -Maternal Harm

Possible causal association

-placenta previa

-spontaneous abortion

Probable causal association

-ectopic pregnancy

-preterm PROM

Causal association

-abruptio placenta

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Tobacco Use During Pregnancy -Infant Harm

Causal association

-low birth weight

-small for gestational age

-preterm delivery

-Sudden Infant DeathSyndrome (SIDS)

-stillbirths

Harms of Tobacco Exposureduring Infancy and EarlyChildhood

Causal association

-otitis media

-new and exacerbated cases ofasthma

-bronchitis and pneumonia

-wheezing and lowerrespiratory illness

Adolescent Smoking

Nearly all smokers begin as adolescents

75% become daily smokers by 20 y.o.

Higher daily consumption, lower quit rate

Female > Male

Affective and Cognitive Components

Vulnerable subset: loss of autonomy with a few cigsalso - greater withdrawal problems

Relationship to maternal smoking during pregnancy?

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Risks to Children Who haveMothers that Smoke

More likely to be hospitalizedduring the first two years of life

Risks to Children Who HaveMothers that Smoke

SUDDEN INFANT DEATH SYNDROMERISKNEARLY TRIPLESWITH MATERNAL SMOKINGDURING AND AFTER PREGNANCY

INATTENTIONADHD

SMOKINGUPTAKE

CONDUCTDISORDER

Adolescence

ASPD

CRIMINALOFFENSES

NICOTINEDEPENDENCE

Adult

SIDS

InfancyInfancy

LOW BIRTH-WEIGHT/

PREMATURITY

STARTLES &TREMORS

Childhood

VERBAL/LEARNINGDEFICITS

EXTERNALIZINGBEHAVIORS

ATTENTIONDEFICITS

Effects of Prenatal Tobacco ExposureAcross Periods of Development

SIDS

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Annual Smoking-Related ChildMorbidity and Mortality

Maternal Smoking During Pregnancy IncreasesRisk of Offspring Behavior Problems

1-2 day old infants - elevated scores on measures of stressand excitability

Toddlers - at increased risk for aggressive behavior,negativity and hyper activity

Teenagers - at risk for memory problems and othercognitive difficulties. cognitive difficulties

and an increase in risk for cigarette addiction duringadolescence.

Environmental Tobacco Smoke (ETS)During Pregnancy

Children of mothers who smoked during pregnancywere found to have thicker walls around thecarotid arteries- making them more susceptibleto stroke and heart attack. This damage appearsto be PERMANENT

Journal of Epidemiology, August 2007

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41

Prenatal secondhand smoke exposure worsensADHD, aggressive behaviors, and poor schoolperformance in these children

Child Psychiatry and Human Development, May 23, 2007

Environmental Tobacco Smoke (ETS)

6,200 children die annually in the US directly related totheir parent’s smoking

2,800 from LBW complications

2,000 from SIDS

1,100 from Respiratory Infections

250 from Burns

Asthma (smaller number)

56% higher chance of being hospitalized in the 1st

year of life

The level of secondhand smoke a child is exposedto at home or in a work environment is directlyproportional to the child becoming a smoker

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42

9/17/2008 10:19:21 AM

43

Percent of pregnant women who reported smoking duringpregnancy on the birth certificate, Annually

7.07

7.49 7.427.83

0

2

4

6

8

10

12

2004 2005 2006 2007 Year toDate

Per

cen

t

Want More Information on the Effects ofTobacco Exposure during Pregnancy?

Go to

Dept. of Health website athttp://www.doh.state.fl.us/Family/mch/SubstanceAbuse/Tobacco/tobacco.html

The Health Consequences of Involuntary Exposureto Tobacco Smoke: A Report of the SurgeonGeneral, 2006http://www.surgeongeneral.gov/library/secondhandsmoke/

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44

Standard 10.1 All providers receiving Healthy Start funding to provide

prenatal care will ask about tobacco use, advise to quit,assist in quit attempt, arrange follow-up, and advise aboutthe dangers of ETS to the pregnant woman, those in herhome, and to infants.

HEALTHY STARTStandards & Guidelines

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9/17/2008 10:19:21 AM

46

9/17/2008 10:19:21 AM

47

Smoking During Pregnancy by Race/Ethnicity—United States, 1989-2003

Source: National Center for Health Statistics, 2004

0

10

20

30

40

1989 1991 1993 1995 1997 1999 2001 2003

Year

Per

cen

t

White

AfricanAmerican

Hispanic

Asian

AmericanIndian

0

10

20

30

40

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year

Per

cen

t

Hawaiian and Part Hawaiian JapaneseFilipino Other Asian or Pacific IslanderChinese

Smoking during Pregnancy, by Asianor Pacific Islander*—United States, 1989-2002

*Determined by the origin of motherSource: National Center for Health Statistics

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48

9/17/2008 10:19:21 AM

49

Tobacco CessationEvidence BasedInterventions

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50

Prenatal Care Provider Tools forTobacco Cessation Counseling

ACOG model-Smoking and Pregnancy: A Clinician’sGuide to Helping Pregnant Women Quit Smoking.2002

Treating Tobacco Use and Dependence: A ClinicalPractice Guideline. UNITED States Department ofHealth and Human Services. Public Health Service.June 2000

Effective Interventionsfor Tobacco Cessation

● Counseling (individual, group, quitlines)

● Pharmacotherapy (6 FDA approved medications)

● Reducing patient out-of-pocket costs (insurance coverage)

● Physician intervention – 5A’s (Ask,Advise, Asses, Assist, Arrange)

● Increasing the unit price of tobacco products

● Smoking bans and restrictions

● Mass media campaigns

● Reminder systems (for clinical settings)

Integrated Approach to TobaccoCessation

CessationPrograms

QUITLINE

HealthSystems/Insurers

Providers/Clinicians

PrivatePurchasers

TobaccoUser

GovernmentPurchaser

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51

5A’S

Treating Tobacco Use & Dependence

Surgeon Generalrecommended “5 A’s”approach

Source:http://www.surgeongeneral.gov/tobacco/clinpack.html

Clinical Practice Guidelines for Brief tobacco cessationCounseling

5 A’s =Make Yours a Fresh Start Family

Ask = SurveyAdvise = Tailor health messageAssess = AssessAssist = Give materials & planArrange = Evaluate progress atfollowup

6

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52

Ask

Identify and document tobacco use for every participant at every visit Identify smokers and recent quitters Determine possible barriers to quitting Identify other smokers in the home

22

Step 1: Survey = Ask

Identify and document tobacco use for everyparticipant at every visit-Can ask participant to choose the statement that bestdescribes them

a. I have never smoked or have smoked less than 100cigarettes in my life.b. I stopped smoking before I found out I waspregnant, and I am not smoking now.c. I stopped smoking after I found out I was pregnant,and I am not smoking now.d. I smoke some now, but I have cut down since Ifound out I was pregnant.e. I smoke regularly now, about the same as before Ifound out I was pregnant.

Source: The American College of Obstetricians andGynecologists, Smoking Cessation during Pregnancytent card.

22

Advise Acknowledge the difficulty of quitting

Give information about the effects of smoking on the fetus, child, smoker

Stress benefits of quitting – relate to motivations person may have mentioned

Give clear recommendation to quit

Positively reinforce recent quit attempts/success at quitting

22

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53

Only 70% of family physicians currentlyask their patients if they use tobacco.

Only 40% take further action.

– -AAFP

Too busy

Lack of expertise

No financial incentive

Expect futility

Don’t want to appear judgmental

Respect for patient’s privacy

Negative message might scare patientsaway

Health professional smokes

AEB1

70% of smokers see a physician each year.

70% of smokers want to quit.

Patients are more satisfied with their healthcare if their provider offers smoking cessationinterventions - even if they’re not yet ready toquit.

AEB2

Slide 158

AEB1 aafpAmy Bannister, 12/13/2005

Slide 159

AEB2 aafpAmy Bannister, 12/13/2005

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54

“As your healthcare provider, Ihave to tell you that quittingsmoking is one of the most

important thingsyou can do for your health.”

Assess

Offer help

Ask if willing to try to quit

Build confidence in ability to quit

162

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55

Assess: Key Questions

Are You Interested in QuittingWith My/Our Assistance?

Are You Ready to Quit in the Next 4-6Weeks?

163

The Process of Behavior Change

Pre-contemplator

Contemplator

PreparationAction

Maintenance

Relapse Ex-Smoker164

PRECONTEMPLATION - NOT READY TO THINKABOUT CHANGE

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CONTEMPLATION - Will listen to new information andconsider the idea of changing behavior - movesslowly toward change.

PREPARATION - Taking a series of steps towardquitting including setting a quit date. ABOUT TOLEAP INTO CHANGE.

ACTION - The first day one stops tobacco use, andthe daily struggle over the next few months tomaintain cessation.

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MAINTENANCE - sustains cessation over a periodof time

RELAPSE - part of the recovery process inaddiction

- when old behavior returns, use learned behaviorchange skills that worked

HOOKED AGAIN

Risk Factors for Smoking Cessation RelapseAfter Pregnancy

Elizabeth Clark, MD, MPH (1,2)

Kenneth D. Rosenberg, MD, MPH (1, 3)(1) Oregon Health & Science University, Portland,

Oregon

(2) University of Iowa College of Medicine, IowaCity, Iowa

(3) Oregon DHS Office of Family Health, Portland,Oregon

9th Annual Maternal and Child HealthEpidemiology Workshop, Tempe, AZDecember 10, 2003

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AssistPURPOSE:

To Assist client

To help the client take positive action toward quittingwhich is appropriate to her readiness to quit

This step provides the foundation for further follow-upand reinforcement

172

Give Materials: Key Notes

Give support Offer the appropriate handouts and review Assist with developing a plan of action Discuss pharmacotherapy Make appropriate referrals (Quitline, groups, etc.) Optional materials Follow-up appointment if possible

173

Arrange Praise positive steps Rephrase initial messages where needed Direct to appropriate pages in materials Build motivation Document status & next steps planned

174

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2 A’s + R

3 MINUTE VERSION

ASK – every patient about tobacco use anddocument in their medical record – 1 minute

ADVISE – urge every tobacco user to quit; employthe teachable moment and link visit findings withadvice – 1 minute

REFER – patients to quitline or cessation classesand document in medical record – 1 minute

Patients Who Decline to Quit: Using the5 R’s

Relevance

Risks

Rewards

Roadblocks

Repetition

5 R’s: Relevance

Ask patient to identify why quitting might bepersonally relevant, such as:

– children in her home

– need formoney

– history ofsmoking-related illness

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5 R’s: Risks

Ask, “What have you heardabout smoking duringpregnancy?”

Reiterate benefits for herunborn baby and her otherchildren

Tell her that a previoustrouble-free pregnancy isno guarantee that thispregnancy will be thesame

5 R’s: Rewards

Your baby will get moreoxygen after just 1 day

Your clothes and hair willsmell better

You will have moremoney

Food will taste better

You will have moreenergy

5 R’s: Roadblocks

Negative moods

Being around othersmokers

Triggers and cravings

Time pressures

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Overcoming Roadblocks:Negative Moods

Suck on hard candy

Engage in physical activity

Express yourself (write, talk)

Relax

Think about pleasant, positivethings

Ask others for support

Overcoming Roadblocks:Other Smokers

Ask a friend or relative to quit with you

Ask others not to smoke around you

Assign nonsmoking areas

Leave the room when others smoke

Keep hands and mouth busy

Overcoming Roadblocks:Triggers and Cravings

Cravings will lessen within a few weeks

Anticipate “triggers”: coffee breaks, socialgatherings, being on the phone, waking up

Change routine—for example, brush your teethimmediately after eating

Distract yourself with pleasant activities: garden,listen to music

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Overcoming Roadblocks:Time Pressures

Change your lifestyle to reduce stress

Increase physical activity

tobacco cessation duringPregnancy: PostpartumMaintenance

Woman’s health

Next pregnancy

Child’s health

Up to 35% of women who stopsmoking during pregnancyremain nonsmokers, benefiting:

Results:Risk Factors for Relapse

Among the women who quit smoking during pregnancy,risk factors for relapse (Odds Ratio, 95% CI):

BivariateMultivariate– Living with other smokers 3.32 (1.38, 8.00) 3.13 (1.28,

7.65)

– Multiparous 2.60 (1.10, 6.14) 2.28 (0.94,5.58)

– Medicaid (at L&D) 2.24 (0.96, 5.23)

– Unmarried 1.83 (0.78, 4.32)

– Black race 1.55 (0.63, 3.80)

– Teen mother (<20 yrs) 0.86 (0.31, 2.40)

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Half of smoking women successfully quitsmoking during pregnancy

60% of women who quit smoking duringpregnancy were still quit at time of survey

Women who lived with other smokers were lesslikely to stay quit

We found that living with other smokers isthe strongest risk factor for relapse.

Programs to decrease smoking among pregnantwomen should include partners

Women are more likely to stay quit for theirfirst baby than for subsequent babies.

Living with other smokers is the strongestrisk factor for relapse.

Programs to decrease smoking among pregnantwomen should include partners

Women are more likely to stay quit for theirfirst baby than for subsequent babies.

Pregnant women who are internally motivatedto quit (for themselves) are more likely tostay quit postpartum than women who areexternally motivated to quit (for theirbaby)*

*Stotts AL et al. Pregnancy smoking cessation: a case ofmistaken identity. Addictive Behaviors. 1996;21;459-471.

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Public Health Implications

More federal support for programs that help pregnant womenquit and stay quit.

Women who live with other smokers need extra social supportto quit and stay quit.

Replicate 5As Screening for prenatal care providers: Ask,Advise, Assess, Assist, Arrange [www.smokefreefamilies.org].

Use of 5As can cause lower relapse rates at one yearpostpartum.*

*Secker-Walker RH, et al. Amer J Prev Med;1998:25-31

Forever Free...For Baby and Me: A Guide to RemainingSmoke Free

“up to 70% relapse after they give birth” Moffitt Cancer Center developed 10 booklets for pregnant and postpartum women based on previous research and interviews with women includes a booklet for the woman’s partner pilot testing Spanish version http://moffitt.org/Site.aspx?spid=C140C11B4963415ABD

1417520E2D9B85 Source: http://moffitt.org/Site.aspx?spid=C140C11B4963415ABD1417520E2D9B85

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Smoking CessationCost Savings

$ Cost of intervention $24-$34

$ Neonatal cost savings $881

per maternal smoker

Source: Costs of a tobacco cessation Counseling Intervention for PregnantWomen: Comparison of Three Settings, Ayadi, Et al, pages 120-126, PublicHealth Reports / March–April 2006 / Volume 121.

Tobacco Cessation Services Provided

– To reduce the incidence of prenatal and post-partum tobacco use

– To reduce the incidence of tobacco use by allhousehold members

– To reduce exposure of the pregnant woman, fetusand infant to environmental tobacco smoke

HEALTHYSTART

Standard 10.3

The Healthy Start participant’s stage of readinessfor change (based on Prochaska and DiClemente’sStages of Change Model) will be reviewed duringeach tobacco cessation service in order to offerthe appropriate service.

HEALTHY STARTStandards & Guidelines

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66

Minimum Components of CounselingCriteria 10.6.d include

– Consequences of tobacco use

– Nicotine addiction

– Pharmaceutical products available fortobacco cessation

– Side effects and contraindications

– Reasons for quitting

– Breastfeeding education for tobaccousers

Standards&Guidelines

Minimum Components of CounselingCriteria 10.6.d include

– Awareness of habits associated with tobaccouse

– Stress reduction methods

– Exercise and nutrition

– Relapse and relapse prevention

– Appropriate disposal

– Danger of smoking while

HEALTHY STARTStandards & Guidelines

Pharmaceutical Aids*

Nicotine patch

Nicotine gum

Nicotine nasal spray

Nicotine inhaler

Bupropion SR (Zyban)

Lozenge

*Unless contraindicated

HEALTHY STARTStandards & Guidelines

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Standard 10.10: Tobacco cessation service providers will develop andimplement an internal quality improvement and quality assuranceprocess

Develop QI/QA process with coalition

– Strengths and areas needing improvement

– Maintenance of quality/ improvement

– Participant satisfaction

– Participant behavioral changes

– Reduction or elimination of tobacco use

– Rate of post-delivery relapse

– Positive health and developmental outcomesHEALTHY STARTStandards & Guidelines

Some Factors to Remember

Treatable

Cycles of relapse and remission

Requires ongoing management, just like diabetesor hypertension

Person requires counseling, support, and,possibly, pharmacotherapy

Clinicians must recognize relapse is common

Are the 5A's Enough?: Tobacco DependenceTreatment for Smokers with Mental Illness

National Conference on Tobacco or Health

October 25, 2007

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From CDC Best Practices, 2007Preventive Services’ Guide to Community Preventive Services

recommends: Increasing the unit price of tobacco products Conducting mass media education campaigns when combined

with other community interventions Mobilizing the community to restrict minors’ access to tobacco

products when combined with additional interventions (strongerlocal laws directed at retailers, active enforcement of retailersales laws, retailer education with reinforcement)

Implementing school-based interventions in combination withmass media campaigns and additional community efforts

CDC Guidelines for School Health Programs to Prevent Tobacco Use andAddiction(An updated version of the guidelines scheduled for release in 2008. Latest available is 1994 )

Develop and enforce a school ontobacco use that establishesenvironments that are tobacco-at all times, including off-siteevents.

Provide a sequential tobacco-useprevention curriculum during K–12, with intensive delivery injunior high or middle school,with reinforcement in highschool

Provide instruction that covers physiologicand social consequences of tobacco use,social influences tobacco use, peer normsregarding tobacco use, and skills thatpromote tobacco-free lifestyle.

Provide program-specific training teachers. Involve parents, families, and community in

support of school based programs to preventtobacco use.

Provide support for tobacco-use cessationefforts among students school staff who usetobacco.

Assess the tobacco-use prevention programat regular intervals.

RTIPS: The only tested and approved programs for clinical andschool settings

1. Title: It's Your Life - It's Our FuturePurpose: Smoking cessation program designed for American Indians in California

2. Title: Kentucky Adolescent Tobacco Prevention ProjectPurpose: Designed to prevent tobacco use among adolescents living in high tobacco production areas.

3. Title: LifeSkills TrainingPurpose: Emphasizes personal and social skills development related to general life skills and substance abuse.

4. Title: Not-On-Tobacco Program (N-O-T)Purpose: Designed to promote cessation and reduce tobacco use among adolescent smokers.

5. Title: Pathways to HealthPurpose: School-based cancer prevention and health promotion program for 5th and 7th grade American Indian students.

6. Title: Physician Counseling Smokers (PCS) ProgramPurpose: Office-based program designed to increase the effectiveness of primary care physician-delivered smoking cessationinterventions

7. Title: Project Towards No Tobacco Use (TNT)Purpose: School-based prevention project designed to delay the initiation and reduce the use of tobacco by middle-school children.

8. Title: Sembrando SaludPurpose: Designed to improve parent-child communication skills as a way of improving and maintaining healthy youth decision making.

9. Title: Spit Tobacco InterventionPurpose: Designed to promote cessation and reduce initiation of spit tobacco use among male high school athletes.

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CLINICAL PRACTICE GUIDELINESCLINICAL PRACTICE GUIDELINES

The Clinical Practice Guidelines provide specificrecommendations regarding brief and intensivetobacco cessation interventions as well assystem-level changes designed to promote theassessment and treatment of tobacco use. Briefclinical approaches for patients willing andunwilling to quit are described.

http://www.surgeongeneral.gov/tobacco/smokesum.htm

9CONTEMPLATION

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70

Risk Factors for Smoking Cessation RelapseAfter Pregnancy

Elizabeth Clark, MD, MPH (1,2)

Kenneth D. Rosenberg, MD, MPH (1, 3)(1) Oregon Health & Science University, Portland,

Oregon

(2) University of Iowa College of Medicine, IowaCity, Iowa

(3) Oregon DHS Office of Family Health, Portland,Oregon

9th Annual Maternal and Child HealthEpidemiology Workshop, Tempe, AZDecember 10, 2003

Introduction

Maternal smoking associations:

– Effects during Pregnancy

• Low Birth Weight (growth retardation)

– Effects in Infancy

• Increased SIDS

– Effects in Childhood and Adolescence

• Increased hyperactivity (ADHD)

• Increased alcohol & drug use as adolescent

• Decreased child IQ

• Increased asthma

Maternal smoking associations:

– Effects during Pregnancy

• Low Birth Weight (growth retardation)

– Effects in Infancy

• Increased SIDS

– Effects in Childhood and Adolescence

• Increased hyperactivity (ADHD)

• Increased alcohol & drug use as adolescent

• Decreased child IQ

• Increased asthma

Public Health Implications

More federal support for programs that help pregnant womenquit and stay quit.

Women who live with other smokers need extra social supportto quit and stay quit.

Replicate 5As Screening for prenatal care providers: Ask,Advise, Assess, Assist, Arrange [www.smokefreefamilies.org].

Use of 5As can cause lower relapse rates at one yearpostpartum.*

*Secker-Walker RH, et al. Amer J Prev Med;1998:25-31

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Nicotine, Tobacco and Brain Damage,Nicotine, Tobacco and Brain Damage,From the Fetus to the Adolescent:From the Fetus to the Adolescent:

Finding the Smoking GunFinding the Smoking Gun

Theodore Slotkin, Ph.D.Theodore Slotkin, Ph.D.

Dept. of Pharmacology & Cancer BiologyDept. of Pharmacology & Cancer Biology

Duke University Medical CenterDuke University Medical Center

Research Support: NIH DA14247 and the Philip Morris External Research Program

U.S. Annual Figures for Maternal Cigarette SmokingU.S. Annual Figures for Maternal Cigarette Smoking

•Spontaneous abortions: 19,000 - 141,000•Low Birthweight: 32,000 - 61,000•Neonatal ICU Admissions: 14,000 - 26,000•Perinatal Deaths: 1,900 - 4,800

•50-500% Increased Incidence of:

•SIDS•Learning Disorders•ADHD•Disruptive Behaviors

Overall US Rate: 10-20% of all births

DiFranza et al, J. Fam. Pract. 1995

ETS exposure: part of the continuum of adverse effects

Fetal nicotine range ≈ 10-30% of active smoking

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Maternal Cigarette Smoking

Effects on Fetal BrainGeneral Development

Hypoxia/IschemiaCO, HCNAnorexia

Maternal-Fetal UnitNicotine in Fetus

Perinatal Morbidity/MortalityGrowth Retardation

Behavioral Anomalies

Risky Behaviors:Other drugs/alcohol

Prenatal CareSocioeconomic

Adolescent Nicotine Effects

Greater Sensitivity of ACh and Serotonin systems• enhanced onset of nAChR upregulation and greater persistence• persistent deficiency in synaptic activity - ACh and Serotonin• exquisite sensitivity - down to level of ‘chipper’ or ETS

Cell damage• loss of synaptic function• brain areas involved in learning and memory, mood

Sex selectivity: effects on females > males (also true for adolescent smokers)

Conclusion: There is a biological basis for thesusceptibility of the adolescent brain to nicotine addiction

2000 PHS Clinical Practice Guidelines

Clinicians and health care delivery systems (including administrators,insurers, and purchasers) should institutionalize the consistentidentification, documentation, and treatment of every tobacco user seenin a health care setting.– Brief tobacco dependence treatment is effective and every patient who

uses tobacco should be offered at least brief treatment.

There is a strong dose-response relation between the intensity of tobaccodependence counseling and its effectiveness.– Treatments involving person-to-person contact (via individual, group, or

proactive telephone counseling) are consistently effective, and theireffectiveness increases with treatment intensity (e.g., minutes ofcontact).

Three types of counseling and behavioral therapies are effective andshould be used with all patients attempting tobacco cessation:

– Provision of practical counseling (problem solving/skills training);– Provision of social support as part of treatment (intra-treatment

social support); and– Help in securing social support outside of treatment (extra-

treatment social support).

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10 5 R’S

TREATMENTSBEHAVIORAL

NRT

Smoking Cessation if more cost-effectivethan other commonly provided clinicalpreventive services, includingmammography, colon cancer screening,PAP smears, hypertension treatment andtreatment of high cholesterol

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Smoking is the most modifiable risk factor for poor birthoutcomes

Successful treatment of tobacco dependence can achieve:

– 20% reduction in low–birth-weight babies

– 17% decrease in preterm births

– Average increase in birth weight of 28 g

Source: Lumley J, Oliver S, Waters E. Interventions for promoting tobaccocessation during pregnancy. Cochrane Database Syst Rev 2000;(2):CD001055.Goldenberg RL, Dolan-Mullen P. Convincing pregnant patients to stopsmoking. Contemp Ob Gyn 2000;35–44. tobacco cessation During Pregnancy.American College of Obstetricians and Gynecologists. ACOG EducationalBulletin Number 260. September 2000.

Conclusions from BehavioralIntervention Studies

Pregnancy is a good time to intervene

Brief counseling works better than simple adviceto quit

Counseling with self-help materials offered by atrained clinician can improve cessation rates by30% to 70%

This brief intervention works best for moderate(<20 cigarettes/day) smokers

44% of FL Women Smokers Atttempted toQuit in 2003

Note: Every Day Smokers whoquit smoking cigarettesfor >1 day during the pastyear.

Source: Behavioral RiskFactor Surveillance System(BRFSS)

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Reasons to QuitReasons to Quit

Avoid tobacco-related illnesses

Save money

Improve physical and athletic performance

Live a healthier life

Improve your sense of smell and taste

Improve circulation

Feel better about oneself

Stop worrying about quitting

Be in control, finally, not the cigarette

Set a good example for children

Benefits of QuittingBenefits of Quitting

Many times those who have smoked for along time do not realize that they canimprove their health by quitting

This is a good time to reiterate this tothem

Review benefits on page 31

Barriers to QuittingBarriers to Quitting

Almost ALL smokers erect barriers, these are back doors thatthey leave open that will keep them from quitting

Here are some of the roadblocks that keep people fromquitting:

I’ll gain too much weight

I’ve cut down already

My spouse will make it hard for me

My friends will offer me cigarettes

Too much stress in my life

I will get irritable when I quit

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226226

Timing of Health BenefitsTiming of Health Benefits

1990 Surgeon General’s Report

20 minutesBlood pressure, heart rate return to

normal

8 hoursO2 level returns to normal; nicotine

and CO levels reduced by half

24 hoursCO is eliminated from body; lungsbegin to eliminate mucus, debris

48 hoursNicotine eliminated from body; taste

and smell improve

72 hoursBreathing is easier; bronchial tubes

relax; energy levels increase

2 to 12 weeksCirculation improves

3 to 9 monthsLung function increases by up to

10%; coughing, wheezing,breathing problems reduced

1 yearHeart attack risk halved

10 yearsLung cancer risk halved

15 yearsHeart attack risk same as forsomeone who never smoked

Call to Action

Smoking is the most modifiable risk factor for poor birthoutcomes

Successful treatment of tobacco dependence can achieve:

– 20% reduction in low–birth-weight babies

– 17% decrease in preterm births

– Average increase in birth weight of 28 g

Source: Lumley J, Oliver S, Waters E. Interventions for promoting tobaccocessation during pregnancy. Cochrane Database Syst Rev 2000;(2):CD001055.Goldenberg RL, Dolan-Mullen P. Convincing pregnant patients to stopsmoking. Contemp Ob Gyn 2000;35–44. tobacco cessation During Pregnancy.American College of Obstetricians and Gynecologists. ACOG EducationalBulletin Number 260. September 2000.

Set a quit date

Tell/enlist family & friends

Anticipate withdrawal / cravings / triggers

Prepare environment

Offer pharmacotherapy

Provide support through the office

Schedule follow up

Intensive Counseling

Quit line

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Counseling/Behavioral Therapies

Counseling should include at least four 30-minute sessions (face-to-face or via telephone)which

– Provide practical counseling that includes problemsolving and skills training

– Teach individuals to enlist outside support from friends,family and co-workers

– Provide individual, group or telephone counseling,focusing on person-to-person support

– Follow-up counseling should be included for recentquitters (less than one year) to prevent relapse

Smoking CessationEvidence-based clinical guidelines on cessation

conclude that:

brief advice by medical providers to quitsmoking is effective

more intensive interventions (individual, group,or telephone counseling) that provide socialsupport and training in problem solving skillare even more effective

FDA approved phamacotherapy can also helppeople quit smoking, particularly whencombined with counseling and otherinterventions

Many pregnant smokers are highlydependent and so find it hard to quit

NRT is not a magic cure

Intensive behavioral support is crucial;to helping pregnant smokers to stop

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Adverse effects ofnicotine areprobably influencedby: DOSE, RATE andROUTE of delivery

Safety of NRT

Cannot be said without risk because it containsnicotine

No good evidence of efficacy in pregnant smokers

But experts agree that there is less risk thancontinued smoking

-smaller dose of nicotine

- slower delivery

- not absorbed into the respiratory system

- doubles the chances of success in thegeneral population of smokers

Weighing up the risks

‘..risk of cigarette smoking during pregnancy is fargreater than the risk of exposure to nicotine.’

‘…use of NRT is probably not without risk…’

‘On balance the use of NRT to aid smokingcessation during pregnancy seem reasonable.’

Benowitz & Dempsey, 2004

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Recommendations

1. NRT be used in combination with behavioralsupport

2. Use the lowest dose of nicotine effective forachieving cessation (oral products better)

3. If cannot tolerate oral products (i.e. due tonausea) use a patch

4. If using a patch, use 16-hr only

5. Initiate treatment as early as possible

Integration for Success

Nicotine Patch duration – 8 weeks is effective

Treatment efficacy using one clinician type increasessuccess by 18.3% (PHS Guidelines, 2000)

Combination of Behavior Modification Therapy andpharmacotherapy (NRT) is more effective than either onealone (Treatment Strategies U. Mass Medical School TTST Manual)

AN “ENHANCEMENT”OF BEST PRACTICE

Some smokers need longer course of treatment

Duration tailored to meet individuals needs. (US Health & HumanServices 10/2000)

Combination of pharmacotherapies – Evidence suggests thatcombining the patch with either nicotine gum or lozengeincreases long-term abstinence rates over those producedby a single form of NRT (US Dept Health Human Service PHS Guidelines, 2000)

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Breastfeeding

Serum concentrations of nicotine in breastfeedinginfants are low

This is even lower in mothers using NRT comparedto smoking

ETS is more risky to the infant

Nicotine Replacement TherapyNicotine Replacement Therapy

Nicotine Patches

Nicotine Gum

Nicotine Lozenge

Nicotine Nasal Spray

Nicotine Inhaler

Buproprion (Zyban)

Varenicline (Chantix)

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Nicotine Replacement TherapyNicotine Replacement Therapy

When smokers stop smoking, nicotine levels drop by halfevery 2 hours

Develop withdrawal symptoms (anxiety, cravings,difficulty concentrating, depression, hunger, irritability,poor sleep, restlessness)

Several products are available

Using NRT doubles your chances of quitting

NRT is safer than smoking because it only has nicotine,not all the other toxins contained in tobacco

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Nicotine VaccineNicVAX™

Early studies on NicVAX®, the Nicotine Vaccine show

• blocks nicotine's entry into the brain

• induces production of long-lasting antibodies thathelped prevent smoking relapse for up to 2 monthsin about a quarter of the study participants

• it to be safe (studies have not confirmed safe useduring pregnancy)

• “this new approach could dramatically enhancethe effectiveness of current treatments fornicotine addiction

Source: Dr. Nora D. Volkow, NIDA Director

PATTERNS OF QUITTINGAMONG ADULTS

Conclusions from BehavioralIntervention Studies

Pregnancy is a good time to intervene

Brief counseling works better than simple adviceto quit

Counseling with self-help materials offered by atrained clinician can improve cessation rates by30% to 70%

This brief intervention works best for moderate(<20 cigarettes/day) smokers

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Percent of Ever Smokers Who have Quit, byRace/Ethnicity—United States, 1978-2004

0

10

20

30

40

50

60

70

1978-1980

1983-1985

1987-1988

1990-1991

1992-1993

1994-1995

1997-1998

1999-2000

2001-2002

2003-2004

Year

Per

cen

t

White

AfricanAmerican

Hispanic

Asian

AmericanIndian

Source: National Health Interview Surveys, 1978-2004, selected years, aggregate data

Percent of Ever Smokers Who have Quit,by Race/Ethnicity—United States, 2003-2004

52.9

45.4

52.5

39.6

33.2

0

10

20

30

40

50

60

70

Per

cen

t

Source: National Health Interview Surveys, 2003-2004, aggregate data

White

AfricanAmerican

Hispanic

Asian

AmericanIndian

Initiation Rates among White Females by BirthCohorts, by Age—United States, 1900-1975

0123456789

101112131415

5 10 15 20 25 30 35

1900 1910 1920 1930 1940 1950 1960 1970 1975

Per

cen

t

Age

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QUITTING AMONG ADOLESCENTS

Quit Attempts in the Past Year, by Gender—United States, 2004

Source: 2004 National Youth Tobacco Survey

Per

cen

t 62.33

51.78

66.88 62.98

0

20

40

60

80

100

Middle School High School

MalesFemales

The 4 D’sThe 4 D’s

• Deep breathe

• Drink water

• Distract

• Delay

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RELAPSE

Relapse Prevention

Avoiding Triggers

What Are My Main Triggers?

Adjustments to Your Lifestyle

HALT: Manage Feelings That TriggerCravings

Relapse PreventionRelapse Prevention

Millions of Americans quit for awhile but return tosmoking/tobacco use. When this happens it is not necessarily afailure! Each quit attempt provides valuable information aboutthe process of quitting

It’s OK to admit the “relapse” and MOVE FORWARD, returningto your goal to quit.

Don’t get down on yourself

Think through the process and choose to get back on track assoon as possible before you revert back to your oldsmoking/tobacco routine

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0

10

20

30

40

50

60

70

1966 1969 1972 1975 1978 1981 1984 1987 1990 1993 1997 2000 2003Year

%F

orm

erS

mo

kers

<12 12 13-15 16+

Percentage of Ever Smokers* Who Have Quit,by Education—United States, 1966-2004

Source: 1966-2004 National Health Interview Surveys*Ever Smoked 100 + Cigarettes†Also known as "quit ratio"; estimates since 1992 incorporate some-day smoking

†

Managing StressManaging Stress

Stress is the leading cause of relapse for smokers

Each year 83% of quitters return to smoking/tobacco usebecause of stress-related problems

Try different stress management techniques until you findwhat works and is comfortable for you

Here are some examples to consider:

Meditation, Stretching, Deep Breathing,

Massage Therapy, Aromatherapy, Exercise,

A healthy diet, music and laughter!

Lifestyle ReviewLifestyle Review

What changes will you make?

Nutrition/Eating

Exercise/Activity Style

Spiritual/Stress Management

Healthy Living

Lifestyle Support Resources

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Nutrition and ExerciseNutrition and Exercise

Research studies show that the nicotine in cigarettesis responsible for increasing your metabolic rate

Due to the higher metabolic rate when smoking, theex-smoker now has a lower metabolic rate and burns100 to 200 fewer daily calories

Nicotine can serve as an appetite suppressant—manypeople rely on that fact to keep their weight down.

H A L TH A L T

Feelings of hunger, anger, loneliness andfatigue may serve as triggers to returnto smoking/tobacco use

Two-thirds (67%) of people return tosmoking when they experience anyof the above feelings for longperiods of time

How Much $$$ Will You Save?How Much $$$ Will You Save?

Each day take the amount of money you spent oncigarettes and put it away.

Reward your hard work with something at theend of the year. You deserve it!

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12 OFFICESETUP

Steps ToImplementation

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CDC Best Practices for Comprehensive Tobacco Control Programs

Establish smoke-free policies and social norms;

Promote and assist tobacco users to quit;

Prevent initiation of tobacco use.

CLINICAL PRACTICE GUIDELINES FOR TREATING TOBACCO USECLINICAL PRACTICE GUIDELINES FOR TREATING TOBACCO USEAND DEPENDENCEAND DEPENDENCE

Treatments are cost-effective

Nicotine replacement therapy

Counseling, social support and outside treatment

Strong dose-response relationship

Brief treatment is effective

Identify, document & treat every tobacco user

Effective treatments exist

Tobacco dependence is a chronic condition

US Public Health Service Guidelines

Clinic screening systems such as expanding the vital signsto include tobacco use status, or the use of other remindersystems such as chart stickers or computer prompts areessential for the consistent assessment, documentation andintervention with tobacco use

All patients should be screened for tobacco use andassessed for their interest in quitting.

All physicians and clinicians should strongly advise everypatient who smokes to quit.

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2000 PHS Clinical Practice Guidelines

Numerous effective pharmacotherapies for smoking cessationexist. Except in the presence of contraindications, these shouldbe used with all patients:– attempting to quit smoking, including bupropion SR, nicotine

gum, nicotine inhaler, nicotine nasal spray, nicotine patch, andthe nicotine lozenge.

– Over-the-counter nicotine patches are effective relative toplacebo, and their use should be encouraged.

Tobacco dependence treatments are both clinically effective andcost-effective relative to other medical and disease preventioninterventions. As such, insurers and purchasers should ensurethat:– All insurance plans include as a reimbursed benefit the

counseling and pharmacotherapeutic treatments identified aseffective in this guideline; and

– Clinicians are reimbursed for providing tobacco dependencetreatment just as they are reimbursed for treating other chronicconditions.”

269

Summary: Reaching TobaccoUsers

Healthcare

Quitlines

Tobaccouser

CommunityCessationPrograms

Referral

Referral Referral

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The Steps for Becoming aTobacco-Free Facility

1. Acknowledge the profoundchallenge tobacco creates for thetreatment community

2. Establish a leadership group orcommittee and secure thecommitment of the organizationin writing

3. Develop a tobacco-free policy

4. Establish a policyimplementation timeline withmeasurable goals & objectives

5. Conduct staff training

6. Provide ongoing recovery optionsfor staff who use tobacco

7. Assess and diagnose tobacco usein patients and use this in treatmentplanning

8. Incorporate tobacco & nicotineinformation in patient educationcurriculum

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9. Establish ongoing communicationwith 12-Step recovery groups,professional colleagues, and referralsources about policy changes.

10. Require staff to not beidentifiable as tobacco users

11. Establish tobacco-free facilityand grounds

12. Implement comprehensivenicotine dependence treatmentthroughout program

Ask all patients

– Vital sign

– Medical record

– Electronic database

Strongly advise all who smoke to quit

Assess willingness to quit

Offer brief or intensive counseling

Prescribe NRT

Arrange for follow-up

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Computerized reminders

Routine cessation advice/brief counseling

Provider incentives

Patient incentives

Quality data

Trained staff

Literature in waiting rooms and exam rooms

Is there a smoke-free policy?

Who smokes and where?

Are cessation services available?

Is there a cessation champion?

Is tobacco a QI indicator?

Is NRT accessible?

How can we help?dbrown@med.miami.edu

What services are available?

How well do they work? CLAS?

What are the barriers?

How do you follow up?

Do you refer to the quit line

Do you bill?

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CODING

REIMBURSEMENT

Tobacco use cessation counseling visit

99406: 3-10 minutes– $ 13.06 non-facility; $ 12.25 – facility

99407: >10 minutes– $ 25.05 non-facility; $ 23.84 - facility

305.1: Tobacco Use Disorder V15.82: History of Tobacco Use Must provide other clinically relevant

diagnosis code, such as cough 786.2

8 visits in 12 months (4 per attempt) Can use modifier - 25 Any eligible provider Inpatient or outpatient

Document time spent counseling

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CONCLUSION

TAKE HOME MESSAGES

Tobacco is an addiction with significant adversehealth consequences

Smoking during the reproductive years isassociated with significant risk to the mother, thefetus, and her children

Effective behavioral and pharmacologicinterventions are available to achieve tobaccocessation

We can implement cessation programs in our dailyclinical practices

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THANK YOU