- 1. CIGARETTE SMOKING, CARDIOVASCULAR DISEASE RISK, AND
IMPLEMENTATION STRATEGIES FOR SMOKING CESSATION Adapted and
Modified from: Luepker RV, Lando HA. Tobacco Use and Passive
Smoking, in: Wong ND, Black HR, Gardin JM, eds. Preventive
Cardiology, Mc Graw Hill, 2000 and NANCY HOUSTON MILLER, R.N.,
B.SN., Stanford University Roger Blumenthal, MD et al ACC
Prevention Guidelines 2007
- 2. Smoking Statement Issued in 1956 by American Heart
Association
- It is the belief of the committee that much greater knowledge
is needed before any conclusions can be drawn concerning
relationships between smoking and death rates from coronary heart
disease. The acquisition of such knowledge may well require the use
of techniques and research methods that have not hitherto been
applied to this problem.
- Circulation 1960; vol. 23
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- 3. Arch Intern Med . 2003;163:23012305. Surgeon Generals Health
Consequences of Smoking, 2004. CDC/NCHS. Tobacco-Related Mortality,
Fact Sheet. CDC.gov/tobacco. February 2004. Heart Disease and
Stroke Statistics2005 Update, AHA. MMWR, Vol. 51, No. 14, 2002,
CDC/NCHS. 33.5% of smoking-related deaths among Americans are
cardiovascular-related Male smokers die an average of 13.2 years
earlier than male nonsmokers Female smokers die an average of 14.5
years earlier than female nonsmokers Current cigarette smoking is a
powerful independent predictor of sudden cardiac death in patients
with CHD Cigarette smoking results in a two- to threefold risk of
dying from CHD Smoking: Mortality
- 4. CHD Risk by Cigarette Smoking. Filter Vs. Non-filter.
Framingham Study . Men 25 cigarettes/day
- Acute MI and sudden death strongly associated with cigarette
smoking.
- Cigarette smoking has additive effect to CHD risk above lipids,
obesity, diabetes, and hypertension
14. Cohort Studies of Environmental Tobacco Smoke and CHD RR (95%
CI) Population Location,Date Source F 1.9 (1.1-3.3) 32046 US 1997
Kawachi M 1.2 (1.1-1.4) F 1.1 (-.96-1.3) 309599 US 1996 Steenland
2.7 (1.3-5.6) 2278 UK 1995 Tunstall-Pedoe M 0.97 (0.7-1.3) F 0.99
(0.8-1.2) 2916 US 1995 Layard 2.0 (1.2-3.4) 7987 UK 1989 Hole M 1.3
(1.1-1.6) F 1.2 (1.1-1.4) 19035 US 1988 Helsing 2.2 (0.7-6.9) 1245
US 1987 Svendsen 2.7 (0.7-10.5) 695 US 1985 Garland 1.2 (0.9-1.4)
91,540 Japan 1984 Hirayama 15. Environmental Tobacco Smoke and CHD
- 35,000-40,000 deaths annually from acute MI are associated with
environmental tobacco exposure, significantly more than due to lung
cancer.
- Recent meta analysis of passive smoking incorporating
home-based and workplace studies (1699 cases) showed relative risk
of 1.49 (1.29-1.72)
- Sidestream smoke released into the environment may be more
toxic and nonsmokers who are exposed regularly develop various
physiologic changes and are more sensitive than regular
smokers.
- Lower HDL-C and platelet abnormalities, higher CO levels and
lower exercise tolerance are noted.
16. Prevention and Intervention Strategies in Youth
- School-based prevention programs
-
- Social environment / influences
- Community-based prevention programs
-
- May enhance effects of school-based programs
- State and federal prevention initiatives
-
- Anti-tobacco media campaigns
-
- Restrictions on tobacco advertising
-
- Restrictions on tobacco availability to minors
-
- Restrictions on smoking in public places including schools
17. Adult Cessation Strategies
- Contingency contracting (wards for abstinence)
- Social support (from clinician, group, family, friends)
- Relaxation techniques (progressive relaxation, deep
breathing)
- Stimulus control and cue extinction (restricting where smoking
takes place)
- Reduced smoking and nicotine fading (gradual reduction)
- Multicomponent treatment programs
- Self-help (written materials, videos, tapes, hotlines,
helplines)
- Computer-tailored messages
18. Time-to-Benefit of Smoking Cessation After Last Cigarette
Within 20 minutes: BP decreases; body temperature, pulse rate
returns to normal Within 24 hours: Risk of MI decreases Within 1
year: Excess risk for CHD is half that of a person who smokes At 5
years: Stroke risk is reduced to that of someone who has never
smoked Within 15 years: CHD risk is the same as a person who has
never smoked American Lung Association.
www.lungusa.org/tobacco/quit_ben.html 19. Counseling: 5 As Ask:
Systematically identify all tobacco-users at every visit Advise:
Strongly urge all smokers to quit Attempt: Identify smokers willing
to try and quit Assist: Aid the patient in quitting Arrange:
Schedule follow-up contact 20. EFFICACY OF SMOKING CESSATION
INTERVENTIONS (1 YEAR QUIT RATES) ACUPUNCTURE ---- HYPNOSIS ----
PHYSICIAN ADVICE 6% SELF-HELP METHODS 14% NICOTINE PATCH 11-15%
PHYSICIAN ADVICE/SELF-HELP PAMPHLETS 22% AVERSIVE SMOKING (RAPID
PUFFING) 25% PHARMACOTHERAPY/BEHAVIORAL THERAPY 25% BEHAVIORAL
STRATEGIES (GROUP PROG.) 40% 21. Tailored vs. generic behavioural
support material % Abstinent at 4 months Self-help materials
tailored for the needs of individual smokers are more effective
than standard materials Strecher VJ. Patient Educ Couns. 1999; 36:
107-117. Strecher VJ, et al. Journal of Family Practice. 1994;
39(3): 262270. 22. Pharmacologic Treatment Options POTENTIAL RISKS
TREATMENT Slight risk of seizure, contraindicated in those with
eating or seizure disorders Zyban (bupropion hydrochloride) May
cause mouth or throat irritation Nicotine inhaler Nose and eye
irritation, usually disappears within 1 week Nicotine nasal spray
Mouth soreness, hiccups, dyspepsia, jaw ache Nicotine polacrilex
(nicotine gum) Skin rashes and irritation Nicotine patch 23.
Nicotine Replacement Therapy Potent psychoactive drug that induces
euphoria Effects are related to blood concentration and the rate of
increase in concentration Safe in patients with cardiovascular
disease Should be used as part of smoking cessation therapy;
however, many individuals may quit without it 24. Smoking and
Nicotine
- Other toxins in tobacco smoke, not nicotine, are responsible
for majority of adverse health effects
-
- >4000 different chemicals
-
-
- Tar, carbon monoxide, irritants, and oxidant gases
- The main adverse effect of nicotine from tobacco is addiction,
which sustains tobacco use
- Nicotine dependence leads to continued exposure to toxins in
tobacco smoke
Smith et al. Food Chem Toxicol. 1997;35:110730. Hoffman and
Hoffman. J Toxicol Environ Health. 1997;50:30764. Benowitz NL.
Nicotine Safety and Toxicity . New York: Oxford University Press,
1998. 25. Nicotine Replacement Therapy (NRT) Goal: Attenuate
symptoms related to nicotine withdrawal Dysphoric or depressed mood
Insomnia Irritability, frustration, or anger Anxiety Difficulty
concentrating Restlessness Decreased heart rate Increased appetite
or weight gain 26. NRT: Treatment Options Forms of NRT: Gum, Patch,
Inhaler, Lozenge, Nasal spray, Sublingual tablet All forms of NRT
appear to be similarly effective NRT choice may be based on
susceptibility to side effects, patient preference, and
availability Little research on combinations of different types of
NRT Limited evidence that adding another form of NRT to the
nicotine patch increases the success rate 27. Plasma nicotine
concentrations for smoking and NRT Minutes Increase in nicotine
concentration ( ng/ml ) Cigarette Gum 4 mg Gum 2 mg Inhaler Nasal
spray Patch 5 10 15 20 25 30 0 2 4 6 8 10 12 14 Balfour DJ and
Fagerstrm KO. Pharmacol Ther . 1996;72:51-81. 28. NRT: Benefit of
Behavioral Support West R, McNeill A and Raw M. Thorax.
2000;55:987-999. Silagy C, et al. Nicotine replacement therapy for
smoking cessation. Cochrane Database Syst Rev. 2002; 1. Limited
Support Intensive Support 29. Safety of NRT
- NRT is safe in most individuals with cardiovascular disease,
even with concomitant smoking
- There is a negligible risk of cancer compared to the risk from
continued smoking
- Although it is a potential fetal teratogen, the benefits
outweigh the risks of smoking during pregnancy
- There is a low risk of abuse
30. Buproprion (Zyban) Sustained release form of the antidepressant
Acts by enhancing CNS noradrenergic and dopaminergic function Start
1 week before smoking cessation date 150 mg QD x 3d, then 150 mg
BID x 60d Higher doses and longer duration with greater side
effects and no clear benefit 31. Buproprion (Zyban) vs. NRT Jorenby
DE et al. N Engl J Med. 1999 Mar 4;340(9):685-91 32. Other
Therapies: Limited Success Clonidine Nortryptiline (tricyclic
antidepressant) Maclobemide (MAO-inhibitor) Buspirone (anxiolytic)
Naloxone (opiate antagonist) Naltrexone (opiate antagonist)
Amphetamines 33. Reduced risk cigarettes
- Includes low tar and light cigarettes, and novel products that
deliver nicotine with minimal tobacco combustion
- Low tar cigarettes have not be shown to substantially reduce
health hazards of smoking but do provide sufficient nicotine to
sustain addiction
- Some novel products may deliver fewer or lower levels of toxins
but some deliver more carbon monoxide.
- Smoking cessation medications are most likely safer than any
reduced risk cigarette
34. Smokeless tobacco
- Snuff or chewing tobacco has been suggested as a potential aid
to harm reduction or smoking cessation
- Such products known to cause oral cancer
- Smokeless tobacco is addictive and not recommended for smoking
cessation
35. THE CLINICAL PRACTICE GUIDELINE ON SMOKING WHATS NEW?
-
- TREATMENT OF TOBACCO MUST BE CONSIDERED A CHRONIC DISEASE
-
- ALL CLINICIANS SHOULD OFFER AT LEAST A 3 MIN COUNSELING
INTERACTION AT EVERY VISIT
-
- ALL SMOKERS WILLING TO QUIT SHOULD BE OFFERED PHARMACOTHERAPY
(EXCEPTIONS: PREGNANT/ BREAST - FEEDING WOMEN, ADOLESCENTS, THOSE
WITH MEDICAL CONTRAINDICATIONS, OR < 10 CIGS/DAY)
36. THE CLINICAL PRACTICE GUIDELINE ON SMOKING WHATS NEW?
-
- CLINICIANS AND HEALTH CARE DELIVERY SYSTEMS MUST IDENTIFY,
DOCUMENT, AND TREAT EVERY TOBACCO USER
-
- INSURERS AND PURCHASERS SHOULD REIMBURSE:
-
-
- a. COUNSELING/PHARMACOTHERAPY FOR
-
-
- b. CLINICIANS WHO PROVIDE TOBACCO
37. PERFORMANCE MEASURES FOR SMOKING CESSATION: HOW DO THEY DIFFER?
-
- AMA - (1) ALL CHRONIC STABLE CORONARY ARTERY DISEASE PTS
IDENTIFIED AS SMOKERS DURING THE REPORTING YEAR
-
- (2) ALL CHRONIC STABLE CORONARY ARTERY DISEASE PTS WHO RECEIVE
TOBACCO CESSATION INTERVENTION IN THE REPORTING YEAR
-
- HCFA - ALL AMI PTS. SMOKING WITHIN ONE YEAR PRIOR TO ADMISSION
WHO RECEIVE SMOKING CESSATION ADVICE OR COUNSELING DURING
HOSPITALIZATION
38. PERFORMANCE MEASURES FOR SMOKING CESSATION: HOW DO THEY DIFFER?
-
- NCQA - BY SURVEY ALL CURRENT/RECENT QUITTERS THAT HAD ONE OR
MORE VISITS INDICATING THEY RECEIVED ADVICE TO QUIT FROM AN MCO
PRACTITIONER
-
- JCAHO - ALL AMI PATIENTS SMOKING WITHIN THE YEAR PRIOR TO
ADMISSION WHO RECEIVE SMOKING CESSATION ADVICE OR COUNSELING DURING
HOSPITALIZATION
39. POINT OF ACCESS: THE USE OF HOSPITALS FOR SMOKING CESSATION
- 30-40 MILLION PEOPLE HOSPITALIZED ANNUALLY
- 20-30% OF HOSPITALIZED PATIENTS SMOKE
- MOST SMOKERS HAVE HAD TO QUIT
- GREATER MOTIVATION TO QUIT
- OPPORTUNITY FOR COUNSELING
40. GENERAL INTERVENTION METHODS
-
- RN INITIATED PHONE CALLS:
-
- NICOTINE REPLACEMENT THERAPY
-
- 1-2 FACE-TO-FACE VISITS AS NEEDED
41. DISSEMINATION OF STAYING FREE SMOKING CESSATION PROGRAM
- TO DETERMINE EFFECTIVENESS OF INITIAL IMPLEMENTATION INTO
SEVERAL HOSPITALS IN SAN FRANCISCO BAY AREA
- TO IMVESTIGATE FACTORS THAT PREDICT SUSTAINABILITY OF STAYING
FREE
42. STAYING FREE INTERVENTION
-
- A STRONG PHYSICIAN MESSAGE ABOUT THE HAZARDS OF SMOKING
-
- A 17 PAGE WORKBOOK ON QUITTING SMOKING
-
- A 16 MINUTE VIDEOTAPE SHOWN AT THE BEDSIDE ABOUT HOW TO REMAIN
AN EX-SMOKER
43. STAYING FREE INTERVENTION
-
- A COUNSELING SESSION AT THE BEDSIDE BY A HEALTH CARE
PROFESSIONAL
-
- PHARMACOLOGICAL THERAPY AS NEEDED
-
- FOLLOW-UP PHONE CALLS FROM HOSPITAL STAFF AND/OR PUBLIC HEALTH
(1 TO 4)
-
- OUTPATIENT REFERRALS TO PUBLIC HEALTH PROGRAMS AND OTHER LOCAL
RESOURCES
44. MODEL I: A VA HOSPITAL PALO ALTO HEALTH CARE SYSTEM
-
- INTERVENTION PROVIDED BY PSYCHOLOGISTS, PSYCHOLOGY INTERNS AND
QUALITY ASSURANCE NURSE
-
- USE OF CLOSED CIRCUIT TV TO SHOW VIDEO
-
- USE OF COMPUTERIZED STAYING FREE TEMPLATES TO DOCUMENT
INTERVENTION IN PATIENTS ELECTRONIC MEDICAL RECORDS
-
- STAYING FREE GROUP E-MAIL CREATED TO DISSEMINATE
INFORMATION/UPDATES TO TEAM
-
- ASK ME ABOUT STAYING FREE ID TAGS FOR STAFF
45. MODEL II: A COUNTY HOSPITAL SANTA CLARA VALLEY MEDICAL CENTER
-
- INTERVENTION PROVIDED BY PHYSICIANS
-
- FOLLOW-UP PHONE CALLS PROVIDED BY SANTA CLARA COUNTY PUBLIC
HEALTH TOBACCO PREVENTION AND EDUCATION PROGRAM
-
- SPANISH AND VIETNAMESE LANGUAGE VERSIONS OF STAYING FREE
-
- CERTIFICATES OF ACHIEVEMENT FOR PATIENTS
46. MODEL III: COMMUNITY HOSPITALS
-
- MILLS-PENINSULA HEALTH SERVICES
-
-
- INTERVENTION PROVIDED BY CARDIAC REHABILITATION AND A DIVERSE
TEAM OF VOLUNTEERS (NURSING STUDENT, FORMER CARDIAC REHABILITATION
PATIENTS, MENDED HEARTS VOLUNTEERS, RETIRED COUNSELORS)
-
-
- DEDICATED STAYING FREE PHONE LINE
-
- COMMUNITY HOSPITAL OF LOS GATOS
-
-
- INTERVENTION PROVIDED BY STAFF CHAPLAIN
-
-
- COMPUTERIZED IDENTIFICATION OF ALL SMOKERS AT ADMISSION
47. MAKING HOSPITAL-WIDE SYSTEM LEVEL CHANGES THAT SUCCEED
-
- DETERMINE PERCENTAGE OF ALL SMOKERS ENTERING A HOSPITAL WHO
SMOKED IN PAST 30 DAYS
-
-
-
- FACE TO FACE CONTACT (2-4 WEEKS)
48. MAKING HOSPITAL-WIDE SYSTEM LEVEL CHANGES THAT SUCCEED
-
- ACTIVELY SCREEN ALL SMOKERS
-
-
- UTILIZE COMPUTERIZED ADMISSION FORM
-
-
- INCORPORATE INTO NURSING HISTORIES
-
-
- INTEGRATE AS PART OF STANDING CCU/CSU ADMISSION ORDERS
-
-
- INCORPORATE AS A VITAL SIGN
49. MAKING HOSPITAL-WIDE SYSTEM LEVEL CHANGES THAT SUCCEED
-
- EXPECT ALL HEALTH CARE PROFESSIONALS TO INTERVENE
-
-
- ASK ABOUT SMOKING STATUS APPROPRIATELY
-
-
- OFFER MOTIVATIONAL INTERVIEW
-
-
- DOCUMENT, DOCUMENT, DOCUMENT (TRACKING FORM, PROGRESS
NOTES)
50. MAKING HOSPITAL-WIDE SYSTEM LEVEL CHANGES THAT SUCCEED
-
-
- ASK ABOUT SMOKING STATUS APPROPRIATELY
-
-
- OFFER STRONG, CREDIBLE MESSAGE ABOUT QUITTING
-
-
- DETERMINE NEED FOR PHARMACOLOGICAL THERAPY
-
-
- DOCUMENT, DOCUMENT, DOCUMENT (MEDICAL RECORD, TRACKING
FORM)
51. MAKING HOSPITAL-WIDE SYSTEM LEVEL CHANGES THAT SUCCEED
-
- CONSIDER A SYSTEM TO OFFER SELF-HELP MATERIALS AND BEHAVIORAL
COUNSELING
-
-
- STANDARDIZE PATIENT EDUCATION MATERIALS
-
-
- UTILIZE CLOSED-CIRCUIT TELEVISION FOR VIDEOTAPES
-
-
- DETERMINE WHO CAN BE TRAINED TO PROVIDE BEHAVIORAL COUNSELING
(ie. VOLUNTEERS, CANDIDATE MEDICAL STUDENTS, CHAPLAINS, NURSES,
PSYCHOLOGISTS)
-
-
- PROVIDE A LIST OF COMMUNITY RESOURCES
52. MAKING HOSPITAL-WIDE SYSTEM LEVEL CHANGES THAT SUCCEED
-
- DETERMINE A MECHANISM FOR FOLLOW-UP
-
-
- USE SMOKING INTERVENTIONISTS TO UNDERTAKE PATIENT
FOLLOW-UP
-
-
- OFFER TELEPHONE CONTACT BY HEALTH CARE PROFESSIONALS ALREADY
MAKING CALLS
-
-
- INTEGRATE CALLS WITHIN PUBLIC HEALTH DEPT.
-
-
- USE CENTRALIZED TELEPHONE SYSTEM FOR ALL SMOKERS WITHIN
COMMUNITY
-
-
- DOCUMENT, DOCUMENT, DOCUMENT
53. Clinicians Guide, Agency for Health Care Policy and Research
54. Quit Smoking Action Plan, American Lung Association