Demographics and Health Effects

1
Demographics andHealth Effects
Office on Smoking and Health National Center for
Chronic Disease Prevention and Health
Promotion Centers for Disease Control and
Prevention USA
Revised 05/06
2
Demographics and Health Effects Section

• Chair Ann Malarcher Centers for Disease Control
  and Prevention, USA
• Peter Anderson Independent Consultant in
  Public Health, Spain
• Mary-Jane Ashley University of Toronto, Canada
• Micah Milton Centers for Disease Control
  and Prevention, USA
• Linda Pederson Centers for Disease Control
  and Prevention, USA
• Jonathan Samet Johns Hopkins University,
  School of Hygiene and Public Health, USA
• Michael Thun American Cancer Society, USA

Revised 05/06
3
Health and Economic Costs of Tobacco Use
4
Global burden of disease and injury
attributableto selected risk factors, 2000
(Total in thousands)
Estimates are based on data and information from
the World Health Organization Childhood and
maternal under nutrition includes vitamin A
Deficiency, zinc, iron under weight 1 Years of
life lost
5

• AFRO African Region
• AMERO Region of the Americas
• EMRO Eastern Mediterranean Region
• EURO European Region
• SEARO South-East Asia Region
• WPRO Western Pacific Region

6
Projected global burden of lung cancer in 2030
Mathers, C., Loncar, D. (2005). Updated
projections of global mortality and burden of
disease, 2002-2030 data sources, methods and
results. World Health Organization
7
Projected global burden of ischemic heart disease
in 2030
Mathers, C., Loncar, D. (2005). Updated
projections of global mortality and burden of
disease, 2002-2030 data sources, methods and
results. World Health Organization
8
Projected global burden of COPD in 2030
Mathers, C., Loncar, D. (2005). Updated
projections of global mortality and burden of
disease, 2002-2030 data sources, methods and
results. World Health Organization
9
Projected global burden of cerebrovascular
disease in 2030
Mathers, C., Loncar, D. (2005). Updated
projections of global mortality and burden of
disease, 2002-2030 data sources, methods and
results. World Health Organization
10
Burden of disease and injury attributable to
tobacco use, 2000
Estimates are based on data and information from
the World Health Organization 1Years of life lost
11
Cancer Death Rates, for Men, US,1930-2003
Rate Per 100,000
Lung
Stomach
Prostate
Colon rectum
Pancreas
Liver
Leukemia
Age-adjusted to the 2000 US standard
population. US Mortality Public Use Data Tapes
1960-2003, US Mortality Volumes
1930-1959, National Center for Health Statistics,
Centers for Disease Control and Prevention, 2006.
12
Cancer Death Rates, for Women, US,1930-2003
Rate Per 100,000
Lung
Uterus
Breast
Colon rectum
Stomach
Ovary
Pancreas
Age-adjusted to the 2000 US standard
population. US Mortality Public Use Data Tapes
1960-2003, US Mortality Volumes
1930-1959, National Center for Health Statistics,
Centers for Disease Control and Prevention, 2006.
13
Smoking-Attributable Mortality Fractions Among
Males in the United States, 2001
Percentage
CDC, Adult SAMMEC, http//apps.nccd.cdc.gov/sammec
/
14
Smoking-Attributable Mortality Fractions Among
Females in the United States, 2001
Percentage
CDC, Adult SAMMEC, http//apps.nccd.cdc.gov/sammec
/
15
Nearly 440,000 Average Annual Deaths
Attributable to Cigarette Smoking United
States, 1997-2001
CDC. Annual Smoking-Attributable Mortality, Years
of Potential Life Lost, and Productivity Losses
United States, 1997-2001. MMWR 200554(25)
625-628
16
Annual Deaths from Smoking Compared with Selected
Other Causes in the United States
Number of death (thousands)
National Center for Health Statistics, Deaths
Final Deaths 2003. National Vital Statistics
Report, 2006 54(13) Annual Smoking-Attributable
Mortality, Years of Potential Life Lost, and
Productivity Losses- United States, 1997-2001
MMWR. 200554(25)625-628.
17

• One out of two lifelong adult smokers will die
  from a smoking related disease.

CDC. Projected smoking-related deaths among youth
United States. MMWR 199645(44)971-974
18
Smoking and Health Among Adolescents

• Rapid addiction to nicotine from early smoking
• More likely to use other drugs (alcohol,
  marijuana, cocaine)
• More likely to be involved in other risky
  behaviors
• Poorer overall health
• Increased resting heart rates

USDHHS. Preventing Tobacco Use Among Young
People A Report of the Surgeon General, 1994
Arday, DR, et al. Cigarette smoking and
self-reported health problems among US high
school seniors, 1982-1989Am J of Health
Promotion 199510(2)111-116.
19
Smoking and Health Among Adolescents

• Increased effects on the respiratory system
• Increased wheezing, gasping and shortness of
  breath
• Increased coughing and phlegm production
• Decreased physical performance
• Decreased endurance
• Reduced lung function
• Slowed growth of lung function

USDHHS. Preventing Tobacco Use Among Young
People A Report of the Surgeon General, 1994
Arday et al. Cigarette smoking and self-reported
health problems among US high school seniors,
1982-1989. Am J Health Promot 199510 111-116.
20
Effects of Smoking and Pregnancy/Reproduction

• Reduced Fertility
• Reduced risk for preclampsia
• Fetal growth restriction
• Increased risk of premature rupture of the
  membranes, placenta previa, placental abruption
  
• Increased risk of preterm delivery shortened
  gestation

USDHHS. The Health Consequences of Smoking A
Report of the Surgeon General, 2004.
21
Effects of Smoking and Pregnancy/Reproduction

• Increased risk of low birth weight
• Increased risk of perinatal mortality (stillbirth
  neonatal deaths)
• Increased risk of reduction of lung function in
  infants
• Increased risk of sudden infant death syndrome
  (SIDS)

USDHHS. The Health Consequences of Smoking A
Report of the Surgeon General, 2004.
22
Health Effects of Secondhand Smoke
23
Contents of Secondhand Smoke (SHS)

• Cigarette smoke contains more than 4000 chemical
  compounds
• Sixty nine chemicals in tobacco smoke are known
  or probable carcinogens
• SHS is a known human carcinogen

USDHHS. The Health Consequences of Involuntary
Exposure to Tobacco Smoke A Report of the
Surgeon General, 2006.
24
An hour a day in a room with smoke is nearly a
hundred times more likely to cause lung cancer in
a non-smoker than 20 years spent in a building
containing asbestos. -Sir Richard
Doll, 1985
25
Health Effects of Secondhand Smoke - Adults

• SHS exposure causes lung cancer among lifetime
  nonsmokers
• SHS exposure associated with living with a smoker
  increases risk of lung cancer by 20-30.
• SHS exposure causes coronary heart disease
  morbidity and mortality
• SHS exposure increases risk of heart disease by
  25-30
• SHS exposure causes increased respiratory
  symptoms of odor annoyance nasal irritation

USDHHS. The Health Consequences of Involuntary
Exposure to Tobacco Smoke A Report of the
Surgeon General, 2006.
26
Health Effects of Secondhand Smoke -Children

• SHS exposure causes sudden infant death syndrome
  (SIDS)
• Maternal exposure to SHS during pregnancy causes
  a small reduction in birth weight
• SHS exposure after birth causes a lower level of
  lung function
• SHS exposure from parental smoking causes lower
  respiratory illness in infants and children

USDHHS. The Health Consequences of Involuntary
Exposure to Tobacco Smoke A Report of the
Surgeon General, 2006.
27
Health Effects of Secondhand Smoke -Children

• SHS from parental smoking causes cough, phlegm,
  wheeze and breathlessness in school age children
• SHS from parental smoking causes exacerbations of
  asthma
• SHS exposure from parental smoking causes the
  onset of wheeze illness in early childhood
• SHS exposure from parental smoking causes middle
  ear disease (acute and recurrent otitis media,
  chronic middle ear effusion)

USDHHS. The Health Consequences of Involuntary
Exposure to Tobacco Smoke A Report of the
Surgeon General, 2006.
28
Approximately, 5 million people will die from
tobacco related illness this year. By 2030, 10
million people will die each year.
World Health Organization. The Tobacco Atlas
(2002). http//www.who.int/tobacco/en/atlas11.pdf
Ezzati Lopez. Estimates of Global Mortality
Attributable to Smoking in 2000. Lancet 2003
362 847-852.
29
Benefits of Cessation
30
Benefits of Cessation Overall

• Former smokers live longer compared with
  continuing smokers
• Smoking cessation reduces risk of premature death
• Risk of death decrease shortly after quitting
• Smoking cessation benefits almost every part of
  the body

USDHHS. The Health Benefits of Smoking Cessation
A Report of the Surgeon General, 1990
31
Smoking Cessation and Lungs

• Lung function starts to improve 2-3 months after
  quitting
• Smoking cessation reduces risk of lung cancer, 10
  years after quitting, the risk of lung cancer
  decreases to 30- 50 that of a continuing smoker

USDHHS. The Health Benefits of Smoking Cessation
A Report of the Surgeon General, 1990
32
Smoking Cessation and the Respiratory System

• Risk of death from Chronic Obstructive Pulmonary
  Disease is decreased after quitting
• Risk of upper and lower respiratory illness such
  as colds, flu, bronchitis and pneumonia is
  lowered
• Coughing, sinus congestion, fatigue and shortness
  of breath decrease 2-3 months after quitting
• Smoking cessation lowers risk of larynx cancer

USDHHS. The Health Benefits of Smoking Cessation
A Report of the Surgeon General, 1990
33
Smoking Cessation and the Heart

• Smoking cessation reduces the excess risk of
  dying from abdominal aortic aneurysm by 50 among
  former smokers
• Risk of coronary heart disease decreases by half
  1-2 years after quitting
• After 15 years of quitting, coronary heart
  disease risk is nearly that of a non-smoker
• Among persons diagnosed with cardiovascular heart
  disease, smoking cessation reduces risk of
  recurrent infarction and cardiovascular death
• After quitting peripheral artery disease
  decreases

USDHHS. The Health Benefits of Smoking Cessation
A Report of the Surgeon General, 1990
34
Smoking Cessation and Other Parts of the Body

• Stroke risk is reduced to that of a never smoker
  after 5 to 15 years of cessation
• Risk of mouth, throat, and esophagus cancers are
  halved five years after quitting
• Bladder cancer risk is halved a few years after
  quitting
• Smoking cessation lowers the risk of kidney,
  stomach, pancreatic and cervical cancer
• Smoking cessation lowers risk of peptic ulcers

USDHHS. The Health Benefits of Smoking Cessation
A Report of the Surgeon General, 1990
35
Smoking Cessation and Pregnancy

• Quitting smoking before or early during pregnancy
  lowers risk of miscarriage, low birth weight of
  baby and SIDS
• Although abstinence early in pregnancy will
  produce the greatest benefits to the fetus and
  expectant mother, quitting at any point in
  pregnancy can yield benefits

USDHHS. The Health Benefits of Smoking Cessation
A Report of the Surgeon General, 1990
36
Summary Health Benefits of Smoking Cessation

• Smoking cessation has major and immediate health
  benefits for men and women of all ages
• Benefits apply to persons with and without
  smoking-related diseases
• Former smokers live longer than continuing
  smokers
• Smoking cessation decreases the risk of lung and
  other cancers, heart attack, stroke, and chronic
  lung disease
• Smoking cessation improves reproductive outcomes

USDHHS. The Health Benefits of Smoking Cessation
A Report of the Surgeon General, 1990
37
Tobacco Dependence
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"In a sense, the tobacco industry may be thought
of as being a specialized, highly ritualized, and
stylized segment of the pharmaceutical industry.
Tobacco products uniquely contain and deliver
nicotine, a potent drug with a variety of
physiological effects."-1972 Claude Teague memo
"RJR Confidential Research Planning Memorandum on
the Nature of the Tobacco Business and the
Crucial Role of Nicotine Therein
39
Frequency of Cigarette Use, 2004
Percentage
SAMHSA (2005), Results from the 20004 National
Survey on Drug Use Health
40
Tobacco Dependence in the United States, 2004

• 35.5 million Americans 12 years or older met the
  criteria for nicotine dependence in the past
  month based on their cigarette use
• 1.1 million youth 12 to 17 years old are nicotine
  dependent cigarette smokers
• The rate of dependence is higher for those who
  start smoking at an earlier age than for those
  who initiate cigarette use later in life

SAMHSA (2005), Results from the 20004 National
Survey on Drug Use Health
41
Nicotine Dependence among Past Month Smokers, by
age, 2004
SAMHSA (2005), Results from the 20004 National
Survey on Drug Use Health
42
Relapse Rate Over Time
100
Heroin
90
Smoking
80
Alcohol
70
60
Abstainers ()
50
40
30
20
10
0
0 1 2 3 4 5 6
7 8 9 10 11 12
Time (Months)
2 Weeks
USDHHS. The Health and Consequences of Tobacco
Nicotine Addiction. A Report of the Surgeon
General, 1988.
43
80,000 to 100,000 young people around the world
become addicted to tobacco, everyday.
World Bank, Curbing the Epidemic Governments and
the Economics of Tobacco Control (Washington
World Bank, 1999).
44
Effective Treatment Interventions
45
Effective Treatment Interventions

• Brief advice to quit from doctors, nurses and
  other healthcare providers
• Group counseling
• Individual counseling
• Telephone counseling
• Pharmacotherapy

Fiore MC, Bailey WC, Cohen SJ, et al. Treating
Tobacco Use and Dependence. Clinical Practice
Guidelines. Rockville, MD U.S. Department of
Health and Human Services. Public Health Service.
June 2000.
46
Identification and Assessment of Tobacco Use

• Assisting the patient in quitting (5As)
• Ask Systematically identify all tobacco users
  at every visit
• Advise Strongly urge all tobacco users to quit
• Assess Determine willingness to make a quit
  attempt
• Assist Aid the patient in quitting
• Arrange Schedule follow-up contact

Fiore MC, Bailey WC, Cohen SJ, et al. Treating
Tobacco Use and Dependence. Clinical Practice
Guidelines. Rockville, MD U.S. Department of
Health and Human Services. Public Health Service.
June 2000.
47
Effective counseling treatment for tobacco use
and dependence

• Practical counseling (problem solving/skills
  training)
• Intra-treatment social support
• Extra-treatment social support

Fiore MC, Bailey WC, Cohen SJ, et al. Treating
Tobacco Use and Dependence. Clinical Practice
Guidelines. Rockville, MD U.S. Department of
Health and Human Services. Public Health Service.
June 2000.
48
Elements of counseling

• Practical Counseling
• Recognize danger situations
• Develop coping skills
• Provide basic information
• Supportive Counseling
• Encourage the patient in the quit attempt
• Communicate caring and concern
• Encourage the patient to talk about the quitting
  process

Fiore MC, Bailey WC, Cohen SJ, et al. Treating
Tobacco Use and Dependence. Clinical Practice
Guidelines. Rockville, MD U.S. Department of
Health and Human Services. Public Health Service.
June 2000.
49
Effective pharmacotherapy for smoking cessation

• Pharmacotherapy that reliably increase long term
  smoking abstinence rates
• Bupropion
• Nicotine gum, inhaler, nasal spray, lozenge and
  patch
• Varenicline
• Clonidine and Nortriptyline can be used if other
  pharmacotherapy is not effective

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Motivational intervention for those unwilling to
quit consist of the 5 Rs

• Relevance Encourage patient to identify why
  quitting is relevant
• Risks Ask patient to identify potential
  negative consequences of tobacco use
• Rewards Ask patient to identify potential
  benefits of quitting
• Roadblocks Ask patient to identify barriers to
  quitting
• Repetition Repeat motivational intervention
  every time unmotivated patient enters a clinical
  setting

Fiore MC, Bailey WC, Cohen SJ, et al. Treating
Tobacco Use and Dependence. Clinical Practice
Guidelines. Rockville, MD U.S. Department of
Health and Human Services. Public Health Service.
June 2000.
51
Recommendations for increasing tobacco cessation

• Increase the unit price for tobacco products
• Mass media education campaigns combined with
  other interventions to inform and motivate
  tobacco users to quit
• Provider reminder systems that identify patients
  who use tobacco products and prompt providers to
  discuss cessation with their client or advise
  client to quit at every encounter

Task Force on Community Preventative Services.
Zaza S, Briss PA, Harris, KW (eds). The Guide to
CommunityPreventative Services. Oxford
University Press. New York, New York, 2005.
52
Recommendations for increasing tobacco cessation

• Provider reminder plus provider education, with
  or without client education
• Reduction of out-of pocket costs for effective
  cessation therapies
• Multi-component interventions that include client
  telephone support

Task Force on Community Preventative Services.
Zaza S, Briss PA, Harris, KW (eds). The Guide to
CommunityPreventative Services. Oxford
University Press. New York, New York, 2005.
53
Recommendations for increasing tobacco cessation

• Standardization of care for routine, effective
  treatment of tobacco use needs
• Continuous screening of tobacco use among those
  who enter the health care system
• Availability of effective intensive treatments
  that includes counseling and pharmacotherapy

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Recommendations for increasing tobacco cessation

• Treatment that emphasizes problem-solving and
  within-treatment and extra-treatment social
  support
• Extended or augmented psychosocial interventions
  beyond minimal advice to quit for pregnant
  smokers
• Institutionalize system changes that are
  essential to ensure that clinical interventions
  occur