Cardiovascular Disease and Tobacco: Where do we go from here

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Cardiovascular Disease and Tobacco Where do we
go from here?

• Scott McIntosh, PhD
• Smoking Research Program, University of Rochester
• Department of Community and Preventive Medicine
• e-mail smcintosh_at_yahoo.com

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Outline of Presentation

• CVD and Smoking
• Epidemiology of Smoking
• Treatment (Cessation) Options

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CVD Risk Behaviors

• A very limited number of health-related
  behaviors practiced by people every day
  contribute markedly to CVD.
• These are Lack of Physical Activity, Poor
  Nutrition, and Smoking.

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CVD Risk Behavior SMOKING

• Cigarette smoking is a major cause of heart
  disease among both men and women.
• Smokers have twice the risk for heart attack as
  non-smokers.
• Nearly 1/5 of all deaths from CVD, or about
  180,000 each year, are attributable to smoking.

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CIGARETTE SMOKING-RELATED ILLNESS
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Cardiovascular Disease DeathsAttributable to
Cigarette Smoking
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CVD Risk Behavior SMOKING

• Smoking is the most important of the known
  modifiable risk factors for coronary heart
  disease in the United States. (Surgeon General)
• Smoking interacts with other risk factors to
  greatly increase the risk for coronary heart
  disease.
• Smoke from other people (ETS) causes up to
  40,000 people to die each year from heart and
  blood vessel disease.

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Cigarette Smoking Interactions with other risk
factors

• The ratio of high-density lipoprotein cholesterol
  to low-density lipoprotein cholesterol is lower
  in cigarette smokers than in nonsmokers.
• Smoking combined with a family history of heart
  disease greatly increases the risk.

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How Smoking Directly affects Cardiovascular
System

• Added strain on heart causes vessels to clamp
  down or constrict.
• If vessels have already been narrowed or damaged
  by heart disease, smoking makes the problem
  worse.
• Smoking causes temporary changes in the heart
  beats faster, BP raises, and blood flow reduces.
• Smoking increases the level of carbon monoxide in
  the blood, which robs the heart and other tissues
  of oxygen.

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Smoking Epidemiology

• 25.2 million men (26.7) and 23.2 million women
  (22.8) are smokers, putting them at increased
  risk of heart attack.
• 4.1 million teenagers age 12 to 17 are smokers,
  and 3,400 Teenagers begin smoking every day.
• If trends continue, approximately 5 million
  persons under 18 years old will die eventually
  from a smoking-attributable disease.

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High School Smokers
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Prevalence () of Current Cigarette Smoking
amongHigh School Students, by Race and Sex,
1991-1997 Smoked cigarettes on at least one of
the 30 days preceding the survey. Source Youth
Risk Behavior Surveys, 1991-1997
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Education
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Per Capita Consumption
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The United States population has Asymptoted
Out just around 25
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Short Long-Term Benefits of Quitting
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Where do we go from here?

• Strides in Research and Practice
• Prevention
• School-based programs
• Treatment
• New focus on Cessation Intervention for Teens
• Theory Development
• Transtheoretical Model of Behavioral Change
  Stages of Change (Prochaska,
  DiClemente, et al.)
• Practical Developments
• AHCPR Guidelines, e.g., for physician
  intervention

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STAGES OF CHANGE

• Transtheoretical Model of Behavioral Change as
  applied to a variety of risk behaviors, not just
  Smoking Cessation
• The stages (using Smoking Cessation as example)
  are
• Precontemplation (Not Considering Quitting)
• Contemplation (Considering Quitting in Near
  Future)
• Preparation (Getting Ready to Quit Soon)
• Action (Taking Necessary Steps to Quit)
• Maintenance (Remaining Abstinent from Cigarettes)
• Relapse/Recycling (Return to an earlier Stage of
  Change)

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Practical DevelopmentsThe AHCPR Guidelines

• AHCPR Guidelines (1996, 2000) Include Reports of
  effectiveness of all recognized, research-based
  Smoking Cessation Strategies, including
• Social Support (e.g., Family/Friends, Classes,
  Phone Support)
• New Behaviors (e.g., Manuals, Beh Mod,
  Relaxation)
• Pharmacology (e.g., NRT, Zyban)
• Minimal Intervention Strategies for Practitioners
• Three Minute Intervention
• The 4 As Ask, Advise, Assist, Arrange

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The AHCPR Guidelines The 4 AsASK, ADVISE,
ASSIST, ARRANGE

• ASK Systematically Identify all Tobacco Users at
  Every Visit
• Office-wide system, document every patient,
  every visit.
• ADVISE Strongly Urge all Smokers to Quit
• Ask every smoker if he or she is willing to make
  a quit attempt
• If not willing to make a quit attempt at this
  time, provide motivational intervention
  (relevance, risks, rewards, repetition).
• Use clear, strong, and personalized manner.

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ASK, ADVISE, ASSIST, ARRANGE

• ASSIST Aid the Patient in Quitting
• Help patient with a quit plan.
• Provide supplementary materials.
• ARRANGE Schedule Follow-Up Contact
• In person or via telephone.
• Should occur soon after quit date, preferably in
  first week.
• Congratulate success or review circumstances of
  relapse.

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Practical DevelopmentsThe AHCPR Guidelines

• AHCPR Guidelines
• Vital Signs to include SMOKING
• Self-Help Interventions
• New Pharmacological Interventions
• Patch and Gum Now Over-The-Counter
• Spray and Inhaler Now Prescription
• Lollipops, Lozenges, Hard Candy, Etc. Being
  Developed
• Zyban (a.k.a., Wellbutrin )

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Tobacco Use as a Vital Sign

• Vital Signs Strategy
• Include SMOKING (Tobacco Use) as a vital sign in
  addition to BP, Pulse, Weight, Body Temperature,
  and Respiratory Rate.
• This example is a sticker for a patients medical
  chart
• A new one should be added to the chart every visit

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Self-Help Interventions

• Clinics are very effective, but only 10 of
  smokers will use them
• Self-Help Methods can include
• Hotline / Proactive Calls
• Manual (Tailored may help)
• Pamphlets / Proact. Mailings
• Medications (NRT, Zyban)
• Behavioral Programs
• Best (most effective) may be a combination of
  these

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Nicotine Gum and Nicotine Patch

• Gum 12mo abstinence 18
• Patch 12mo abstinence 25

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Medication Zyban (a.k.a., Wellbutrin )

• Only Non-nicotine medication shown to be
  effective (19 abst. at 6 mos)
• Works on both craving and withdrawal pathways
  in the brain
• Can be used with NRT
• 8 to 12 weeks, but currently trials are assessing
  longer treatment
• Begin ONE WEEK before Cold Turkey Quit Date
• Many physicians prescribe Wellbutrin instead
  Same Drug, should be used same way, with
  behavioral component
• 36 Abstinence at 1 month, 19 Abstinence at 6
  months

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New Funding PossibilitiesThe Lawsuits

• Class Action Lawsuits in landmark decisions are
  occurring at the State and Federal levels
• 9/22/99 the U.S. Department of Justice filed a
  lawsuit seeks monetary recovery for the more than
  20 billion a year that the Federal Government
  spends on treating smoking-related diseases under
  Federal health programs
• However, these funds are often earmarked for
  non-Tobacco Control efforts
• Funding should go directly to Tobacco Control
  Efforts Prevention, Treatment, and Research

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Program DevelopmentPoints to Keep in Mind

• Classes / Clinics should be about 30 minutes
  long, with between 4 and 7 sessions
• Problem-solving /skills training
• danger situations
• coping skills
• information on smoking and quitting
• The 4 Rs
• Relevance
• Risks
• Rewards
• Repetition
• Provide Relapse Prevention Intervention
• Include Pharmacotherapy

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References

• DiClemente, CC, Prochaska, JO, et al. (1991) The
  Process of Smoking Cessation An Analysis of
  Precontemplation, Contemplation, and Preparation
  Stages of Change. Journal of Consulting and
  Clinical Psychology, 59(2)295-304.
• Fiore MC, Wetter DW, Bailey WC, et al. (1996)
  Smoking Cessation Clinical Practice Guideline.
  Rockville, MD Agency for Health Care Policy and
  Research, Public Health Service, US Department of
  Health and Human Services.
• Gilpin EA, Choi WS, Berry C, Pierce JP (1999) How
  many adolescents start smoking each day in the
  United States? Journal of Adolescent Health, 25
  248-255.

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CVD and Tobacco

• THANK YOU
• Scott McIntosh, PhD
• Smoking Research Program, University of Rochester
• e-mail smcintosh_at_yahoo.com