Smoking Cessation and Perinatal Issues

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Smoking Cessationand Perinatal Issues

• Scott McIntosh, PhD
• University of Rochester
• School of Medicine and Dentistry
• Department of Community and Preventive Medicine
• 585.273.3876
• scott_mcintosh_at_urmc.rochester.edu

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Our Smoking Society

• Facts
• Single most preventable cause of death
• 430,000 Americans die per year
• 50 times that of illegal drug deaths
• Teen smokers 34.8
• Advertising
• Spends 18 million per day
• 18-24 year olds are a target

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Annual Deaths Attributable to Smoking in the
United States
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Our Smoking Society

• Financial Costs to Society
• 150 billion in annual health related economic
  losses
• 75.5 billion in medical expenditures
• College Students Are Smoking More
• Estimated 60 have tried tobacco products

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Table 8.4
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Tobacco and Its Effects

• Tobacco Products Are Harmful
• Cloves 40 ground cloves (a spice) 60 tobacco
• Cigars
• Bidis small, hand-rolled, flavored cigarettes
• Smokeless tobacco

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Tobacco and Its Effects

• Physiological Effects of Nicotine
• Stimulates CNS
• Stimulates adrenal glands
• Increases production of adrenaline
• Increases heart rate
• Increases respiratory rate
• Constricts vessels

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Tobacco and Its Effects

• Health Hazards of Smoking
• Cancers
• Lung 85-90 associated with smoking
• Pancreatic
• Lip
• Esophagus
• Tongue

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Tobacco and Its Effects

• Health Hazards of Smoking (continued)
• Cardiovascular Disease
• Smokers have 70 higher death rate
• Stroke
• Smokers are 2 times more likely to suffer stroke

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How Cigarette Smoking Damages the Lungs
Figure 8.2
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Health Hazards of Smoking

• Respiratory Disorders
• Chronic bronchitis
• Emphysema
• Sex Life
• Males are 2 times more likely to suffer
  impotence
• Other Problems
• Gum disease
• More likely to need medications
• Metabolism of drugs is affected

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Health Hazards of Smoking

• Ladies, How about a Smokers Beard?!
• Smoking may give you bad breath, smelly clothing,
  yellow teeth -- but a beard??!! A recent study of
  more than 50,000 women found that those who
  smoked more than a pack of cigarettes a day were
  50 percent more likely to have excessive facial
  hair than nonsmokers. The study attributed the
  abnormality to the affects smoking has on the
  balance of male and female hormones and the
  medical and cosmetic consequences of tobacco use.

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• Smoking Really Does Stunt Your Growth!
• A study from Harvard University shows that
  smoking only a few cigarettes a day decreases
  lung growth among young people. "It was
  surprising that we could determine an effect of
  smoking on lung growth so early in the process,"
  says Dr. Diane Gold. "Some would say that it
  takes many years to see an effect." While
  nonsmokers' lungs continue to grow between the
  ages of 10 and 18, lung capacity falls for 10- to
  18-year-olds who smoke as few as five cigarettes
  a day. Reduced lung capacity means that lungs
  hold less air. That means less air for running,
  football, gymnastics, tennis, baseball -- for the
  rest of your life. ("Smoking stunts youths'
  lungs," USA Today, 9/26/96.)

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• So, Youre Not a Long-Term Smoker?
• According to student journalists responding to an
  informal Tobacco News Service questionnaire
  during the California Statewide High School
  Journalism Convention in Anaheim, about half of
  those who smoke think that they want to quit at a
  later date. This is similar to studies that show
  only five percent of high school seniors who
  smoke daily think they definitely will be smoking
  in five years. However, almost 75 percent of them
  are still smoking five to six years later.
  (Tobacco News Service, "Student Tobacco Use
  'In' or 'Out'?", 11/96. National Institute on
  Drug Abuse, 1993.)

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• Smoking Affects Menstrual Periods
• Cigarette smoking can have adverse effects on a
  woman's menstrual periods, according to a report
  in the March, 1998 issue of the journal
  Epidemiology.
• At the University of Virginia, Charlottesville,
  Dr. Paige P. Hornsby and colleagues found that
  compared with nonsmokers, smokers experienced
  more days of pain before and during their
  periods. The study also showed that the women who
  smoked most reported the most days of pain.
  Smokers had shorter periods than nonsmokers, but
  they bled more heavily on the first two days.
  Hornsby's team asked 358 women, ages 37 to 39, to
  keep a menstrual diary for six months. In this
  group, 275 women were nonsmokers, 35 were light
  smokers, and 48 smoked more than half a pack of
  cigarettes per day.

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• Smoking Affects Menstrual Periods
• Smoking Affects Menstrual Periods "Biological
  mechanisms for the effects of smoking on menses
  are not clear," Hornsby and her colleagues
  comment. Some theories advanced by other
  researchers are that cigarette smoke is toxic to
  the ovaries, that smoking changes the way the
  central nervous system regulates hormones, and
  that smoking inhibits the production of estrogen.
  SOURCE Epidemiology (19989193-198)

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Environmental Tobacco Smoke (ETS)

• Risks from ETS
• Mainstream smoke drawn thru tobacco while
  inhaling
• Sidestream smoke from burning end of cigarette
  or smoke exhaled by smoker more carcinogens
• ETS is responsible for deaths
• Sidestream smoke causes more deaths a year than
  any other environmental pollutant
• Children exposed

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Quitting

• Benefits of Quitting
• According to the American Cancer Society, many
  tissues will repair themselves

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When Smokers Quit
Figure 8.3
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Scope of the Problem

• Negative consequences of tobacco use arewell
  established
• Few colleges have resources to devote tonicotine
  addiction
• Many college students experiment and/or are
  addicted to nicotine
• Nicotine addiction often becomes habitual in
  college

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Scope of the Problem, contd.

• Tobacco use among college students on the rise
• Up 28 over last few years (Weschler 1998)
• Freshmen rates up by 31.2
• Lowest increase among seniors at 25.3
• More females (29.2) than males (27.5)
• Ever smokers" (11) had their first cigarette
  afterage 18
• Current smokers (28) began to smoke regularly
  afterage 18

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Hurdles to Health

• Prevention/cessation efforts not geared toward
  college students
• Current programs do not appeal to college
  students
• 40 of colleges do not offer cessation programs
• Lack of programs tailored to college-specific
  environment
• Targeted approach is essential with this
  population

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Marlboro Marketing

• 1924 introduces Marlboro as a womans
  cigarette, Mild as May
• 1927 ad Women quickly develop discerning
  taste. That is why Marlboros now ride in so many
  limousines, attend so many bridge parties and
  repose in so many handbags.

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Current Marlboro Marketing
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Smoking Prevalence in the U.S.
JAMA, 1989261
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Women and Smoking --Basic Facts

• In 1998, 22 of women smoked cigarettes
• Since 1980, approximately 3 million US women have
  died from smoking-related diseases
• Each year in the 90s US women lost approx. 2.1
  million years of life due to these premature
  deaths
• About 90 of lung cancer deaths among women are
  attributable to smoking

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142,000 Deaths Attributable to Cigarette Smoking
in Women - United States, 1990
Ischemic Heart Disease
Lung Cancer
Stroke
Other Diagnoses
Chronic Lung Disease
Other Cancers
CDC, MMWR, 8-27-93
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The Paradox of Gender

• In the overall population, women and men quit
  smoking at similar rates (5)
• Among smokers who present for treatment studies,
  women, in general, quit at lower rates than men
• Data suggests that girls who initiate smoking
  will smoke for approx. 4 years more than boys
  (Pierce Gilpin, 1996)

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Possible Mechanisms

• Differences in dependence
• Differences in withdrawal
• Differences in affective regulation
• Differences in reinforcing properties of nicotine
• Differences in efficacies of pharmacotherapy

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Withdrawal

• Nicotine withdrawal symptoms include negative
  affect (e.g., sadness, anxiety, anger), inability
  to concentrate, hunger, disrupted sleep, and
  cravings (Welsch, 1999)
• Nicotine withdrawal has a number of parameters
  that are related to relapse (Piasecki, 1999)

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Affective Regulation

• Women are twice as likely to suffer from major
  depression (APA, 1994)
• Women are more likely to report increased
  depressed mood during cessation (Pomerleau, 2003)
• Women are more likely to report using cigarettes
  to regulate their negative affect

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Reinforcing Properties of Nicotine

• Data suggests that women find the associated
  properties of cigarette smoking (e.g., smell,
  flavor) more reinforcing than men (Perkins, 1999)
• Recent animal data suggests that female rats will
  work for secondary reinforcers (e.g., a light
  that signals nicotine delivery) more than male
  rats (Caggiula, 2002)

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Conclusion

• Given the enormous health impact of smoking on
  both men and women, it is important that we
  understand both the similarities as well as
  differences in men and womens patterns of
  tobacco use.
• Possible gender differences emerge in withdrawal
  symptoms, negative affect and affect regulation,
  nicotine reinforcement, and pharmacotherapy
  effects.

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Point-of-care clinician opportunity
teachable moment
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Smoking during pregnancy is a major risk factor
for pregnancy related illness and death, and has
been linked to

• 30 - 70 increase of miscarriage
• 20 - 30 risk of still birth
• 30 increase in perinatal mortality
• 80 increased risk of placenta praevia for
  16-20/day
• smokers
• 20 increase in the risk of placental abruption
  for every ½
• packet smoked

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Risk for the infant

• Smoking in pregnancy linked to
• Behavioral problems
• Respiratory problems
• The rate of infant mortality is 40 higher in
  smokers.
• Sudden Infant Death Syndrome
• Babies born to smokers are up to 15 times more
  likely to die of cot death (risk increases with
  the number of cigarettes smoked)
• Even those who smoke between 1 and 9 cigarettes a
  day, the risk to their babies is 5 times greater
  than non-smokers.

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• However although well documented that smoking
  in pregnancy is harmful, 30 of women who smoke
  continue to smoke during pregnancy (HEA 99)

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What is it like being a pregnant smoker?

• I feel got at and victimised.
• I think its wrong and I would be better not
  smoking but its not so easy now that Im
  pregnant myself
• I wish I could give up but like everyone says
  its not easy at all to do.
• When Im out I feel as though people, the public
  in general are thinking bad things. They might be
  thinking I could be jeopardising the babys
  future and they might think Im very selfish. I
  thought the same when my friend was pregnant
  years ago I thought she shouldnt be smoking

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Materials Design Targeted Materials

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NEED 3 THINGS TO STOP SMOKING

• The 3 most important factors that predict a
  successful Quit Attempt
• Social Support (e.g., Family/Friends, Classes,
  Phone Support, Changing Society)
• New Behaviors (e.g., Manuals, Behavior
  Modification, Relaxation, Dealing with Stress)
• Pharmacology (i.e., N.R.T. Zyban)
• Fiore et al. (2000)

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National Institute of Clinical Excellence
Guidance (march 2002)

• The use of NRT in pregnant and breast feeding
  mothers who
• could not quit without a cessation aid, could
  be considered
• following a R/B analysis by a health
  professional who should
• take into account
• the significant harm associated with continuing
  to smoke and
• that it can be expected that NRT will deliver
  less nicotine (and
• none of the other potentially disease-causing
  agents) that
• would be obtained from cigarettes. (Para 3.2)

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Smoking is an Addiction AND a Habit

• Although an addiction, Smoking has a BEHAVIORAL
  COMPONENT that must be recognized and changed.
• Learning new behavioral ways to cope with stress,
  to relax, etc. are all part of a successful plan
  of action.
• Smoking is the most important of the known
  modifiable risk factors for disease in the United
  States. (Former Surgeon General David Satcher)

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Effective pharmacotherapies should be used with
all patients trying to quit.

• First line medications
• OTC
• Nicotine Gum
• Nicotine Patch
• Nicotine Lozenge
• PRESCRIPTION
• Nicotine Inhaler
• Nicotine Nasal Spray
• Bupropion SR

• Second line meds
• PRESCRIPTION (Off Label only)
• Clonidine
• Nortriptyline

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Nicotine Replacement Therapy Maintain addiction
while breaking the habit
Blood Nicotine Levels Red Cigarette Green
Average Daily Level Blue Nicotine Replacement
Therapy (NRT)
(Withdrawal Symptoms)
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GRATCC

• The goal of GRATCC (Greater Rochester Area
  Tobacco Cessation Center) is to train 13 clinical
  sites in Year 01 in Public Health Service
  guideline-based intervention and support for
  screening, treating, and referring patients for
  Nicotine Dependence.
• The 13 sites include Family Practices throughout
  the 5-County area, a Mental Health clinic, a
  chemical dependence Rehabilitation Clinic, and an
  OB/GYN practice. Clinicians (MDs, PAs, NPs)
  and all office staff will be trained on-site, and
  followed with ongoing support services and
  evaluation (Scott McIntosh, PhD, Deborah J.
  Ossip-Klein, PhD).

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GRATCC

• 10 to 15 clinical sites per year will be added in
  Years 02-05.
• GRATCC will provide
• an in-house intensive training for clinicians at
  least 2 times per year (Geof Williams, MD), and
• an intensive treatment option for 200 referred
  patients to a Rochester-based treatment program.
• Partners include ACS, ALA, AHA, Strong Health,
  BC/BS, Monroe Plan, and all local State-funded
  Tobacco Control initiatives, such as the County
  Action Coalitions and Reality Check for teens.
• In addition, all 5 county Departments of Health
  and the New York State Department of Health are
  partners, as is the New York State Quitline.

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GRATCC

• 2 of GRATCCs 13 sites are OB/GYN
• 1) Dr. Faig Morogos Sodus (rural)
• 2) Dr. Julius Avorkliyah West Main OB/GYN
• located in the inner-city area of Rochester
• connected to West Main Pediatrics (trained by us
  previously provider and office systems,
  technical support potential site for
  pediatrician interventions with parents at well
  visits)
• houses a Healthy Start Rochester project,
  supported by The Perinatal Network of Monroe

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GRATCC

• All three sites (OB/GYN, Pediatric, and "Healthy
  Start"), share the same office staff, offering
  unique opportunity to build infrastructure for 3
  "health care facilities (as defined by State
  Tobacco Control) training and technical support
  will be streamlined, and facilitate increased
  efficiency in the application of screening, 5A
  intervention by providers, and office systems
  maintenance and support.

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New York State Quitline

• Increased referral options beginning 2005
• Medicaid Uninsured
• Proactive Calls
• Free Nicotine Replacement
• Interactive Website (With Cessation in October,
  2004) nysmokefree.com
• Up to date referral to local cessation options
• 1-866-NY-QUITS

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One Opportunity Qweb.org

• 86 of college students are wired to the
  internet
• 72 check email and/or go online at least 1x/day
• Most access the web for health-related
  information
• Broad dissemination
• Individualized experience
• Represents and respects diverse experiences

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Benefits of College Environment

• Great Window of Opportunity for cessation
  efforts
• Behavioral changes in college can prevent
  lifelong habits/patterns of use
• 85 of health directors consider tobacco use and
  nicotine addiction to be a problem on their
  campuses

References Emmons et al, 1998 Wechsler, 2001
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What Works

• Motivational enhancement
• Tailored, personalized interventions
• Harm reduction approach?
• Is one cigarette OK?
• Can YOU be a CHIPPER?

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• Ladies Smoking Even One Cigarette Could Kill
  You!
• Smoking ANY number of cigarettes before age 16
  could quadruple your chance of getting breast
  cancer later in life. Girls who smoke and have a
  weak version of a cancer-neutralizing enzyme --
  which millions of American women have -- see
  their risk for breast cancer skyrocket. More than
  55 percent of whites, 35 percent of blacks and 10
  to 20 percent of Asians have the weak gene,
  according to a Journal of the American Medical
  Association study. ("Smoking linked to breast
  cancer," The New York Times, 11/13/96 "Focus
  Smokeout on teen girls," Oakland Tribune,
  11/19/96.)

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QWEB.ORG

• Interactive web-based multimedia program
• Offered to students at colleges/ universities
• Helps students understand, reduce, and stop
  tobacco use
• Allows students to created personalized tobacco
  use profile

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Websites Self Assessments

• Smoking Habits, Beliefs, Behaviors
• Motivation to Change
• Self- Efficacy and Confidence
• Students Perceived Level of Stress

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• QUITTING
• Articles
• Strategies
• Polls
• Quizzes
• Fact Cards

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• ARTICLES
• Related Strategies
• Did You Know?
• Rate Myself
• Related Tools
• Quizzes

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• ASK THE EXPERT
• Specific questions answered from national experts
  in the field
• Related articles
• Past Questions of the Week
• Rate Myself
• Quizzes

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Interactive Tools

• Body Sense
• IQ The Informed Quitter
• Cost Calculator
• Rate Your Risk
• You Know You Are A Smoker/Dip User When . . .

• Tobacco Ingredient Checklist
• Peer Stories
• Excuses, Excuses
• Quitting Calendar
• Cigarette Engineering Tool

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THANK YOU!

• Scott McIntosh, PhD
• Department of Community and Preventive Medicine
• 585-273-3876
• scott_mcintosh_at_urmc.rochester.edu