Objectives

• Familiarize physicians with the impact of tobacco use on patients and society
• Introduce the concept of smoking as a complex behavior
• Help physicians understand their role in the cessation process

A Very Brief History of Tobacco

1492: Columbus "discovers" tobacco
1519: First appears in Europe
1543: Tobacco recommended for it’s medicinal purposes.  Thought to cure:   
           Plague, Headaches, Scabies, Labor pains, Asthma, Cancer
1600’s: Pipe smoking becomes prominent, smoking spreads throughout Europe
              and the Americas. -- Tobacco used as a currency
1800’s: Technology developed to create cigarettes, Nicotine isolated
1900’s: Cigarettes conquer the world!!
             – Mellower tobacco encourages inhalation
             – Women begin smoking
             – Soldiers were given cigarettes during WWI and WWII
             – Health Effects Discovered
1937: Cancer produced in lab rats by cigarette tar
1950: Smoking linked to lung cancer, carcinogens identified
1964: First Surgeon General’s report
1965: Health warnings appear
1970: Radio/TV ads banned
1999: Tobacco settlement with States

Consequences of Smoking, Medical Consequences, & Smoking Related Illnesses

• MI’s, strokes CAD
• Almost all cancers
• Emphysema and COPD
• Chronic Bronchitis
• Respiratory infections
• Peripheral vascular disease
• Aggravation of asthma

Health Consequences of Smoking

• Increase acid secretion in stomach
• Impotence and infertility
• Increased risk of children’s respiratory illness, asthma and ear infection
• Increase in LDL, decrease in HDL
• Disruption of menstruation and menopause
• Major risk factor for bacterial meningitis
• Increase in risk in SIDS
• Reduced immune response
• Premature aging and wrinkling
• Increased risk of developing cataracts and macular degeneration
• Gum disease and other oral problems
• Reduced exercise tolerance

Monetary Consequences

• The average pack-a-day smoker spends about $2,000 a year on cigarettes
• In a lifetime most PA smokers could buy their house with what they spend on cigarettes
• Economic Liability: $50 to 73 billion per year in additional medical costs

Societal Consequences

• Smoking is the leading preventable cause of death and disability in the world
• Over 10 million premature deaths in the US since 1964
• The average loss of life: 7 years
• U.S. tobacco companies still spend an over $8 billion on domestic advertising

What is a Cigarette?

• Drug Delivery System
• Designed to deliver a specific amount of nicotine
• Design
• Filter
• Porosity of paper
• Burn Rate
• PH of smoke

Other Characteristics

• Brand specific characteristics
• Amount of tar/Co/Nicotine
• Taste/Flavor
• Individual variations:
• Amount of inhalation
• Depth of inhalation
• Duration of inhalation

Complexity of the Smoking Behavior

• The Three Aspects of Smoking
• Physical Addiction
• Habit
• Psychological Dependency

Physical Addiction

• Addictive Substance: Nicotine
• Reinforcer
• Releases neurotransmitters in brain
• Produces Pleasure
• Gets to brain in one to two minutes
• Withdrawal Syndrome
• Levels begin to drop immediately
• Negative feelings occur

Typical Smoking Pattern

• Usually in withdrawal upon waking
• First cigarette leads to quick peak
• Serum levels begin to drop immediately upon completion of cigarette
• Withdrawal occurs
• Next cigarette is smoked to relieve withdrawal
• Pattern is repeated throughout the day

Theory of Addiction

• Pleasure reinforces repeated use
• Withdrawal encourages repeated use
• Acclimation occurs
• Smoker self-titrates nicotine levels to stay at or above comfort level
• Wide individual variability

Amount of Nicotine in Cigarettes

• Strains of tobacco with higher nicotine content being used
• Concentrated nicotine added to some brands
• Ammonia added to change the PH in mouth so that more nicotine is absorbed

Nicotine Absorption

• Readily absorbed: Peak Concentrations:
• Respiratory tract: 1-2 minutes
• Nasally: 5-10 minutes
• Orally: 10-15 minutes
• Skin: 6-9 hours
• Minimal stomach absorption due to acidity

Effects of Nicotine on Body

• Effects depend on dose
• Stimulant/tranquilizer
• Releases neurotransmitters
• Increases respirations
• Increases GI tone and motor activity
• Some evidence to suggest it facilitates memory/decreases aggression
• Slight shift in metabolism

Withdrawal

• Irritability
• Anxiousness
• Impatience
• Restlessness
• Depression
• Sleep Disturbances
• Cravings
• Increased Appetite

Smoking Cessation Medications

• Significantly reduces or eliminates all these symptoms
• Delays/Decreases: Increase in appetite, weight gain

Nicotine Toxicity

• Perspiration
• Dizziness
• Nausea/vomiting/diarrhea
• Differences: Withdrawal/toxicity
• Toxicity is physical
• Withdrawal is emotional
• Very rare even with concomitant use of NRT and smoking

Habit

• "Automatic" Smoking
• Linking smoking with other behaviors
• Engaging in this paired behavior causes unconscious urges to smoke

Typical Trigger Situations

• Morning Routine
• Coffee
• After Meals
• In the car
• On the phone
• Alcohol
• Stress
• Anger
• Anxiety
• Boredom
• Celebration

Psychological Dependency

• The mistaken belief that cigarettes are doing something positive for the smoker
• The added belief that this is something the smoker can not do on his or her own

Perceived Benefits of Smoking

• It helps me deal with stress
• It helps me manage my weight
• It helps me regulate my moods
• It’s my best friend
• Other

Smoking as a Chronic Disease

• Very strong physical and psychological components that precipitate relapse
• Quitting is a process that occurs over time
• It is not a discrete one time event
• Most smokers need four or five attempts before the quit "sticks"
• Ongoing, rather than acute care is most productive
• Relapse is a natural part of the process
• Despite chronic nature many effective treatment regimes exist
• Physician's can play an important role in increasing quit rates

Why Physicians Don’t Counsel Quitters

• Time Constraints
• Lack of Reimbursement
• Lack of Knowledge/Skills
• Misperception of need

Time Constraints

• Powerful smoking cessation interventions can be done in three to five minutes
• Simply telling a patient to quit may have profound effects
• Surveys indicate that almost half of smokers say that no healthcare provider has told them to quit!
• Clinical Practice Guidelines show that three to five minute counseling from Physician's greatly increases quit rates

Reimbursement Avenues

• PA Medical Assistance now covers counseling and medications
• Many private insurances are beginning to institute coverage
• Can fold in counseling with treatment/testing for smoking co-morbidities
• Explore self pay

Lack of Knowledge/Skills

• PA AHEC is now offering a series of CME classes to provide physicians with the necessary skills and knowledge
• Clinical Practice Guidelines outline simply protocol for physician counseling
• Training opportunities exist for support personnel to gain knowledge/skills if MD can not do intense counseling

Misperception of Need

• Smoking is not a "lifestyle choice" outside of the purview of the medical profession
• It is an addiction, a chronic condition that requires, in most cases, healthcare intervention
• Tobacco use is the leading cause of death and disability in the world
• Physician's can have a profound impact on the success of a quit

What Can You Do?

• Make quitting a prominent message to all smoking patients
• Do not give any patient permission to continue to smoke
• Make cessation options available
• Assist all patients in quitting
• Have cessation literature in office
• Be aware of cessation programs in your area
• Refer

How to Assist Patients: What You Can Do

• Develop a plan
• Select a smoking cessation medication
• Provide support and encouragement
• Teach and promote coping
• Provide materials
• Arrange for follow-up

Develop a Plan

• Pick a quit day
• Reinforce motivations
• Break through barriers
• Help the patient understand what situations are likely to be a problem
• Strategies about specific ways of dealing with those situations

Encourage and Support

• Always emphasize that quitting is "doable"
• Do not focus on how hard it is to quit
• Be a "cheerleader"
• Encourage continued coping

Select a Smoking Cessation Medication

• Over-the-Counter
• Patch
• Gum
• Lozenge
• Prescription
• Oral Inhaler
• Nasal Inhaler
• Zyban
• Separate training on all products available

Teach and Promote Coping

• Coping: Learning to deal with the desires, urges, and triggers for a cigarette without smoking
• Change what you do
• Change how you think
• Offer specific suggestions for problem situations

Provide Materials

• Have educational materials available in your office
• Refer patients to:
• Local group or individual cessation programs
• Behavior modification programs provided with each cessation product
• State Hot Line: 1 877 724-1090

Arrange for Follow Up

• Quitting is a process that occurs over time
• It is not a discrete one-time event
• Follow up should be negotiated based on needs of each patient
• In office
• By phone
• What to do?
• Prevent relapse: Develop targeted coping
• Monitor medication compliance
• Provide support

The U.S. Department of Health and Human Services
Clinical Practice Guideline: Treating Tobacco Use and Dependence

• Advocates the 5 A’s
• Available from Agency for Healthcare Research and Quality: 800 358-9295
• Clinical Practice Guidelines
• Quick Reference Guide
• Consumer Version

Five A’s

• Ask every patient about tobacco use
• Advise all smokers to quit
• Assess willingness to quit
• Assist patient in whatever way you can
• Arrange for follow up

Why Counsel ?

• It is the right thing to do
• Tobacco use directly impacts the condition of every smoking patient you see
• Smoking causes real pain and suffering in many individuals
• Smoking impacts the health of all other household members

Other AHEC Programs

• Practical Office Interventions: Counseling Smokers to Quit
• Practical Pharmacology:  Treatment of Tobacco Dependency
• Reimbursement for Smoking Cessation Treatment