Addressing Persistent Tobacco Use in Persons with Cardiopulmonary DiseaseAudrey Darville, PhD, APRN, CTTSCertified Tobacco Treatment SpecialistUK HealthCare/UK College of NursingMarch 5, 2015

Impact of Smoking on the Heart

At age 50 years with >2 risk factors, lifetime risk of CVD is:• 50% for a woman• 70% for a man

Age at ACS admission • Male smokers were more than 9 years younger

than the nonsmoking men • Female smokers were more than 13 years

younger than the nonsmoking women

Lloyd-Jones D. Circulation. 2010Go AS. Circulation. 2013Howe M. Am J Cardiology. 2011

INTERHEART—Risk of first MIPopulation Attributable Risk (%)

Yusuf S. Lancet. 2004

36

10

20

33

0

20

40

60

80

Smoking Psycho-social Lipids

18

Diabetes Abdominalobesity

Hyper-tension

50

Impact of Smoking on the Lungs

Even low levels of tobacco smoke significantly effect smoking-responsive genes in the small airway epithelium

Strulovici-Barel, et al. American Journal of Respiratory and Critical Care Medicine DATE

Smoking, COPD & GenderLung function reduction and COPD severity

were the same for male and female subjects, but women were:• younger • started smoking at a later age• had smoked fewer pack-years Differences were more pronounced in the early-

onset and low exposure COPD subgroupsSorheim, et al. Thorax. 2010

So Why Do People Use Tobacco?

The Tobacco Industry wants us to believe tobacco use is a personal choice

Case Study

Mr. J., 46, has severe heart disease from multiple heart attacks and continues to smoke 2 PPD. When asked about his tobacco use, he replied it had nothing to do with his heart attacks, so there was no point in talking about it as he just gets “ugly” when he doesn’t smoke.

What was the origin of his beliefs?

• After his heart attacks his doctor told him he needed to cut out eating salt and fat and lose weight. He said “nothing about smoking” (that the patient heard)• Many family members smoke and their hearts

were OK• Stress would kill him faster than smoking and his

life was pretty stressful• “If someone tells me to do something, I’m going to

do the opposite. That’s just how I am.”

Is he ready to quit (and does it matter)?•Consider how complex it is to describe

the effects of tobacco on the heart•Consider his experiences with tobacco

and quitting

Is it the Habit or the Drug?

• “Choice” is the Tobacco Industry message…• Do we consider tobacco use (nicotine

addiction) a chronic disease?• Addiction is not logical: We generally

won’t convince someone that nicotine patches are cheaper than cigarettes• Are we dispelling “myths of smoking”

effectively?

Cessation “Myths” to be challenged

• In order to quit you really have to want to quit• Medications are more harmful than smoking• Some people just can’t/won’t quit• Medicine won’t work unless you want to quit• You don’t need to talk about it, you just need to

do it• Don’t try to quit smoking when you’re trying to

get sober or quit drugs, it’s too stressful• Reducing your smoking or switching to

smokeless/e-cigs are better for your health

What’s Motivation Got to Do with It?

•What constitutes “Motivation”?•How is it different than “Readiness”?•What is the clinical evidence for the role of motivation in behavior change?

Motivation

According to Google…• The reason or reasons one has for

acting or behaving in a particular way.• The general desire or willingness of

someone to do something.

Components of Motivation

Importance/Salience“I really have to quit”“Smoking is killing me”

Confidence/Self-efficacy“I’m too stressed to quit right now”“I’ve tried to quit so many times”

Readiness versus Motivation

•Readiness focuses on the barriers•Motivation explores the REASONS behind the barriers

The Science in a nutshell…

•Motivational interviewing may help people quit and is widely used•Most effective when used by trained

professionals• Avoids aggressiveness and confrontation•More is better

Motivational interviewing for smoking cessation (Cochrane Review). 2010

How it WorksA content analysis of a Randomized Control Trial found counseling:• Supports confidence about quitting and reduces perceived

difficulty quitting• Prompts avoidance of access to cigarettes• Improves quitting self-efficacy• Reduces perceived difficulty of quitting over time• Protects against guilt and demoralization following lapses• Supports the importance of receiving social support• Strengthens motivation and confidence• Eases withdrawal distress during cessation efforts

McCarthy, et. al. Addiction. 2010.

Understanding Disparities…• “Nicotine-dependent individuals

with a comorbid psychiatric disorder made up 7.1% of the population yet consumed 34.2% of all cigarettes smoked in the United States”• Persons with mental illness die, on

average, 25 years younger than the general population

Grant, B.F. , et al. Archives of General Psychiatry 2004.

Putting it into PracticeQuit Rulers:

Helpful to Know…• Age of onset of smoking• Nicotine dependence (high if time to first cigarette is

30 minutes or less)• Prior quit attempts/methods used• Exposure to other smokers/secondhand smoke

Components of Effective Counseling

Promoting Importance of Quitting:Develop discrepancies between

current behavior and desired behaviorPromoting Confidence to quit:

Develop a plan and engage useful tools (including medication) to assist in changing behavior

Tailored Approaches Work: Reducing to Quit

• A Cochrane Review (Lindson, Aveyard & Hughes, 2010) found 10 studies that looked at reducing cigarettes prior to quitting compared to making no change in CPD smoked• Found no significant difference between

the 2 strategies in quit rates, concluding either strategy can be recommended for quitters (tailoring)

ROADBLOCK: Switching to Quit (aka Harm Reduction)?

• Strategy that is causing international controversy in tobacco control• Involves promoting the use of alternate

products (smokeless tobacco including snus, electronic cigarettes most commonly)• A significant amount of harm reduction

science receives funding from the tobacco industry

Is Less Harmful=Not Harmful?• Tobacco industry is aggressively marketing

smokeless and novel tobacco products, such as e-cigarettes, as “less harmful” alternatives to smoking traditional cigarettes• Smokeless use has been associated with an

increased risk of fatal MI and Stroke Piano, et al (2010), Yatsuya & Folsom (2010)

E-cig Concerns• FDA regulation is pending: No current

standards exist• Particulates, including tin, have been found in

the inhaled vapor Williams, et al., Plos One, 2013

• Acute pulmonary effects similar to tobacco smoke effects have been seen in electronic cigarette users Vardavas, et al. Chest 2012

• Case report of lipoid pneumonia attributed to e-cig use McCauley, et al, Chest, 2012

E-cig Marketing Forces At WorkNow that big tobacco companies are major players in the e-cig market there has been an explosion in marketing (déjà vu?):

Additional Evidence-Based Techniques• Expressing Empathy: “What do you like

about smoking? How does it help you?”• Rolling with Resistance: “It’s hard to find a

good time to quit. What do you think will help you move forward?”• Supporting self-efficacy: “Tell me how the

medication is doing for you.”

The Full-Court Press•With cessation treatment, more is always

better• Counseling (in person, online, text support)

plus medication most effective at helping people quit and STAY quit• Quitline is FREE, EFFECTIVE and EASY via

electronic referral at: https://www.quitnowkentucky.org/eReferral/

Arming Yourself (resources)

• www.smokefree.gov• Treating Tobacco Use and Dependence Clinical

Practice Guideline: http://www.ahrq.gov/path/tobacco.htm • Association for the Treatment of Tobacco Use

and Dependence: www.attud.org• Free CE: http://

www.cecentral.com/ManagingNicotineWithdrawal

Questions Now or Later…

Audrey Darville, PhD, APRN, CTTSCertified Tobacco Treatment SpecialistUniversity of KentuckyCollege of Nursing450F CONLexington, KY 40536-0232audrey.darville@uky.edu 859-323-4222