Tobacco Cessation In Special Populations

Eric L. Johnson M.D.

Assistant Professor

Department of Family and Community Medicine

University of North Dakota

School of Medicine and Health Sciences

Objectives

• Identify the scope of tobacco’s impact in North Dakota

• Discuss common disease states associated with tobacco use

• Discuss and apply tobacco cessation needs for special populations

Special Populations• Diabetes- already at high risk for

cardiovascular disease, smoking as a cause/exacerbation of diabetes

• Pregnancy- poorer pregnancy outcomes• Mental Illness/Chemical Dependency- -

high utilization, difficult to treat• Adolescents- Difficult to engage, limited

data on medications• Native Americans- High utilization, barriers

Overview of Tobacco

Smoking Causes Death

Smoking causes approximately

• 90% of all lung cancer deaths in men• 80% of all lung cancer deaths in women• 90% of deaths from chronic obstructive

lung disease (COPD)

CDC

Smoking Causes DeathCompared with nonsmokers smoking

increases risk of—• Coronary heart disease by 2 to 4 times• Stroke by 2 to 4 times• Men developing lung cancer by 23 times• Women developing lung cancer by 13 times• Dying from chronic obstructive lung diseases

(COPD) by 12 to 13 times

CDC

Secondhand Smoke DeathsUnited States• Lung cancer – 4,000 deaths annually • Ischemic heart disease – 45,000 deaths

annually

North Dakota• 80-140 deaths annually

CDC

% Adults who smoke

BRFSS 2009, CDC

State by State Smoking

Tobacco Use in North Dakota

• ~100,000 ND adults and ~8,000* HS students smoke cigarettes

• ~20,000 ND adults and ~3,800^ HS students use spit tobacco

(BRFSS 2008)

(YRBS 2005,2007,2009)

Tobacco Use in North Dakota• Between 2001 and 2009, Adult

smoking rates in North Dakota dropped from 23.2% to 18.6%

• Highest West Virginia 25.6%

• Lowest Utah 9.8%

• About half of smokers report cessation attempts annually

Behavioral Risk Factor Surveillance System (BFRSS)MMWR

Tobacco’s Health Cost inNorth Dakota

• Smoking-attributable direct medical expenditures:

$250,000,000• Smoking-attributable productivity costs:

$192,000,000• Medicaid expenditures for smoking-related illnesses and

diseases:

$47,000,000

Annual Costs! CDC. Smoking-Attributable Mortality, Morbidity and Economic Costs (SAMMEC) report, 2008. CDC Data Highlights, 2006.

General Issues in Smoking Cessation

• Triggers• Mood changes• Withdrawal symptoms (most smokers

underestimate)• Weight gain• Lack of support• Exposure to other smokers

Tobacco Cessation Counseling

• Brief counseling (i.e., 5A’s)• Classes• Quitline/Quitnet/Quitplan• 3rd party payer programs

Pharmacotherapy

• Nicotine replacement therapy (NRT)• Bupropion (Zyban, Wellbutrin) • Varenicline (Chantix)

• First-line therapies USPHS Guidelines 2008

Smoking and Diabetes

Smoking and Diabetes• Strong Association between smoking

history and development of Type 2 Diabetes

• Now thought to be an independent risk factor, like obesity

• Several large studies to date with more recent interest

• Already a high risk CVD population• Glucose control may be worse

Does smoking cause diabetes?

• Growing evidence points to smoking as an independent risk factor for developing diabetes

• Large prospective studies with multivariate adjustments still do point to a causal link

Smoking and Diabetes Risk

• Women’s Health Study RR 1.42 AJPH 1993

• Men’s Health Professionals Study RR 1.94 BMJ 1995

• Osaka Study RR 1.47- 1.73 Diabetes Med 1999

• Physician’s Health Study RR 2.1 Am J Med 2000

• Cancer Prevention Study 1 RR 1.45-2.1 I Jour Epi 2001

Smoking and Diabetes

• The Translating Research Into Action for Diabetes (TRIAD) Study

• Smoking increased relative risk of all cause mortality of 1.44

McEwon, et al Diabetes Care 2007

Passive (Second Hand)Smoking and Diabetes

• The High-Risk and Population Strategy for Occupational Health Promotion (HIPOP-OHP) study

• Relative risk of type 2 Diabetes 1.81 with secondhand exposure

• Relative risk of type 2 Diabetes 1.99 for active smokers

Hayashino, et al Diabetes Care 2008

Effects of smoking on diabetes

• Increased random and fasting glucose • Increased HbA1C• Increased insulin resistance• All these despite a lower average BMI

• Recent study showed 9.8% of youth with diabetes smoke Reynolds, et al ADA meeting abstract 2008

Haire-Joshu, et al Diabetes Care 1999

Medications for Smoking Cessation in Diabetes

• NRT• Buproprion• Varenicline (Chantix)

• All can be used in diabetes, avoidance of weight gain important

Tobacco and Diabetes• Smoking is a cause of type 2 diabetes• Smoking worsens diabetes control• Smoking increases risk of CVD and other

complications• Smoking cessation is critical in diabetes• Consider appropriate medications• Refer to ND Quitline/Quitnet, MN Quitplan, other

local resources

Tobacco and Pregnancy

Tobacco Cessation in Pregnancy

• Benefits in pregnancy and long term health (interventions in younger women)

• Reduce Cardiovascular Complications• Reduce Lung Disease• Reduce Cancer• Reduce Type 2 Diabetes• Economic benefit for individual and society

Smoking in Pregnancy

• Smoking in pregnancy higher in North Dakota than national average: 18% vs. 11%

• Smokers tend to be from lower socioeconomic and educational classes

• WIC smoking population as high as 40%+ in North Dakota

North Dakota Department of Health

Smoking in Pregnancy

• ~75% of pregnant smokers desire quitting• ~25-30% actually quit during pregnancy• ~50% resume after pregnancy• Smoking Cessation is most successful

prior to pregnancyRuggiero L, et al Addict Behav. 2000 Mar-Apr;25(2):239-51Ebert LM Fahey K Women Birth. 2007 Dec;20(4):161-8Tong VT, et al Am J Prev Med. 2008 Oct;35(4):327-33.

Complications of Smoking in Pregnancy

• Fourfold increase in small for gestational age; Increased prematurity

• Twice the rate of spontaneous abortions• Increased risk of abruptio placentae,

placenta previa, premature and prolonged rupture of membranes

Russell, T, et al Nicotine & Tobacco Research, Vol6, Supp 2. Apr. 2004Gabbe: Obstetrics 4th ed 2002 George L, et al Epidemiology. 2006 Sep;17(5):500-5Faiz AS, Ananth CV.J Matern Fetal Neonatal Med. 2003

Complications of Smoking in Pregnancy

• Intrauterine growth restriction• Stillbirth• Ectopic pregnancy• Infertility• Poor wound healing/surgical outcomes

Russell, T, et al Nicotine & Tobacco Research, Vol6, Supp 2. Apr. 2004Gabbe: Obstetrics 4th ed 2002 Högberg L, Cnattingius G. BJOG. 2007 Jun;114(6):699-704.

Fetal/Child Effects of Maternal Smoking in

Pregnancy• Sudden infant death syndrome (SIDS) and

increased respiratory illnesses in children • Possible Association with maternal

smoking and ADHD/Behavioral Disorders• Congenital Anomalies (i.e., cleft lip/palate,

cardiac)Linnett KM, et al Pediatrics 2005; 116: 462-467Malik S, et al Pediatrics 2008 Apr;121(4):e810-6Shi M, et al Am J Hum Genet. 2007 Jan;80(1):76-90

Smoking Cessation Interventions in Pregnancy

• Brief Office Counseling• Smoking Cessation Class (i.e., Public

Health)• Third Party Payer programs• Quitlines• Online programs (i.e., Quitnet)• Pharmacologic

Pharmacotherapy for Pregnant Smokers

• NRT- Category D. Secreted in breast milk. Crosses placenta

• Buproprion (Wellbutrin, Zyban)- Category B. Metabolites in breast milk. Risk of seizure (low). Increase spontaneous abortion 1st trimester?

• Varenicline (Chantix)- No data (yet)

Oncken CA, Kranzler HR Nic Tob Res Nov 2009

Pharmacotherapy for Pregnant Smokers

• USPHS 2008 more limited recommendations vs USPHS 2000

• ACOG 2005: NRT for heavy smokers if other nonpharmacologic interventions fail

Pharmacotherapy for Pregnant Smokers

• NRT use must be risk vs benefit

-heavy smoker, relapsers, other risk ? (i.e. CVD risk factors)

-if NRT used, intermittent (gum, lozenge)

-higher birth weight?• Buproprion? 1 study shows benefit *• Varenciline- not recommended presently

*Chan B et al J Add Dis (24) 19-23 2005

Pharmacotherapy for Pregnant Smokers

• Smoking, Nicotine, and Pregnancy Trial• Currently underway (UK study)• Projected publication is 2013

• Pregnancy affords a great opportunity• Multiple short term followup clinic visits• Phone calls/e-mail/quitline/quitnet• ASK every time• Options every time• North Dakota data encouraging

Smoking Cessation Interventions in Pregnancy

Tobacco Use and Mental Illness

Tobacco Use and Mental Illness

• Tobacco use in patients with a psychiatric diagnosis ~41%

• Tobacco use patients without a psychiatric diagnosis ~20%

Lasser, et al JAMA 2000

Tobacco Use and Mental Illness

• Lifetime quit rates for ever smokers with a psychiatric diagnosis 16%-26%

• Lifetime quit rates for ever smokers without psychiatric diagnosis ~42%

• Persons with mental illness consume 30-50% of all tobacco sold in the U.S.

Lasser, et al JAMA 2000Fagerstrom and Aubin Curr Med Res Op 2009

Mental Illness Smoking Rates

• Schizophrenia 80%+• Depression 40-60%• Bipolar Disorder 40-70%• Anxiety Disorders 20-50%• PTSD 50-65%

Factors Influencing Smokingin Mental Illness

• Nicotine may improve symptoms of schizophrenia

• Nicotine may improve symptoms of depression

• Withdrawal from nicotine may exacerbate symptoms in mental illness

Dalak, et al Am J Psych 1999Malpass and Higgs Psychopharm 2007

Smoking Cessation Interventions in Mental

Illness• Brief Office Counseling (5 A’s)• Smoking Cessation Class

(i.e., Public Health, Lung Association)• Third Party Payer programs• Quitlines• Online programs (i.e., Quitnet)• Pharmacologic

Considerations/Complications of Smoking Cessation Therapy In Mental

Illness• Tobacco can lower serum levels of some

psychiatric drugs • Induction of CYPIA2• Therefore, cessation may alter serum

levels of some psychiatric drugs• Monitoring for side effects, change in

status, etc important

Fagerstrom and Aubin Curr Med Res Op 2009

Management of Emergent Psychiatric Symptoms in Tobacco Cessation

• Monitor for symptoms• NRT +/- buproprion if appropriate

(depression)• Adjustment of other psych medications• Cognitive behavioral therapy (CBT)• Motivational Interviewing• Varenicline?

Can exacerbate some symptoms

Medications for Tobacco Cessation in Mental Illness

• NRT: Be aware of interactions with psych meds, but more data

• Buproprion: May be useful to co-manage depression, depends on other meds used

• Varenicline: Not a lot of data, but can exacerbate some symptoms

Fagerstrom and Aubin Curr Med Res Op 2009

Tobacco Use and Chemical Dependency

Tobacco and Chemical Dependency

• We treat all other aspects of chemical dependency simultaneously

• Nicotine (tobacco) is an addictive drug with adverse health effects

• Treat chemical dependency, need to lower risk of dying prematurely from a tobacco related disease in recovery

Nicotine Dependence in the Chemically Dependent Population

• Smoking rate in the general population ~20%• Smoking rate in the chemically dependent

population ~80+%

• Smoking is more deadly to chemically dependent population:

4 times the death rate of non-smokers

51% of deaths from tobacco

33% of deaths from drugs or alcoholCDC 2005; Walsh, etal Drug & Alcohol Review (24) 2005; Hurt, et al Alcoholism: Clin & Exp Res (18) 1994

Benefits of Smoking Cessation in CD Treatment

• Smoking tobacco and drinking alcohol are strongly inter-related

Gulliver, et al J Stud Alc 2000

• Urges to smoke = Urges to drink

Cooney, et al Psych Addict Beh 2007

• Increased smoking = Increased drinking Barrett, et al Drug Alc Dep 2006

• Other concomitant addictions are treated

Benefits of Smoking Cessation in CD Treatment

• Smoking Cessation integrated into treatment without jeopardizing recovery goals

Cooney, et al Psych Addict Beh 2007

• Smoking Cessation can improve drinking outcomes

Friend and Pagano J Sub Ab Treat 2005

• Tobacco Counseling may reinforce alcohol treatment Friedmann, et al J Sub Ab Treat 2005 Kalman, et al J Sub Ab

Treat 2006

Pharmacotherapy in CD Treatment

• Nicotine Replacement Therapy may be more important

Hurt Alcoholism: Clin and Exp Res 2002

Hurt, et al Addiction 1995

• Buproprion (maybe): Contraindicated in history of head injury,seizures, or an ongoing risk for withdrawal syndrome

• Varenicline (maybe): Monitor psych status, not enough data in CD population

Tobacco and Adolescents

Adolescent Smoking in ND

• 22.4 % Grade 9-12• 7.3 % Grade 7-8• 47 % Grad 9-12 smoked at least once• 53 % of the current smokers in grades 9-

12 tried to quit smoking during the previous year

YRBS 2009

Adolescent Smoking Cessation Barriers

• Difficult to engage (some trials end because of low enrollment/dropouts)

• Difficult to comprehend long-term health consequences

Smoking Interventions in Adolescents

• Direct counseling increases quit rate to ~11% (about 6% with ‘usual care’

• Counseling of parents may be of benefit• Presently USPHS has no specific

medication recommendation• NRT has been shown to be safe• Tobacco Taxes as intervention?• School based prevention?

Tobacco and Native Americans

Tobacco Use in Native Americans

• Native American population: 49.3% adults use tobacco (highest smoking rate of any ethnic group in U.S.)

• Quitline utilization has been good in North Dakota (~8% of all callers, 6% of total population)

Tobacco Cessation in Native Americans

• Needs to be culturally significant and relevant

- i.e.,true ceremonial use not a cessation focus- Specialized programs “All Nations Breath of Life”• Like other populations, urban vs rural different• Low cost of tobacco is a cessation barrier on

reservations

Summary

• Common special populations with tobacco cessation needs

• Different approaches for different populations

• Some type of counseling (brief in office, Quitline/Quitnet/Quitplan, class, etc) can be used for all

Contact us

eric.l.johnson@med.und.edu To schedule a lecture/conference or to

request materials, please contact:Melissa Gardner

Phone: 701-777-3191 melissa.gardner@med.und.edu

Slide Decks/Media

• Media Links:• Dr. Johnson's Slide Decks

http://www.med.und.edu/familymedicine/slidedecks.html