Sarah
Woolsey, MD,
FAAFP
Medical Director
HealthInsight
Utah, and
CHC, Inc.
UTAH, THE US, AND
“A cigarette is the only consumer product which
when used as directed kills its consumer.”
-
Dr. Gro Harlem Brundtland
Former WHO Director General
No conflicts of interest
Understand current tobacco and electronic cigarette
usage rates in Utah and the US
Utilize evidence-based techniques for smoking
cessation interventions with patients and families
Understand how to integrate free cessation services
into your clinical setting
UTAH AND US NICOTINE ADDICTION: BY
THE NUMBERS
TOBACCO PREVENTION AND CONTROL IN UTAH Fifteenth Annual Report, August 2015 http://www.tobaccofreeutah.org/pdfs/tpcpfy15report.pdf
UT
US
Deaths/year
1,200
480,000
Conventional Use
9.50%
16.80%
E-cig Use
4.80%
3.70%
Smokers that want to quit
in next 12 months
73%
68.90%
DISPARITIES AMONGST US ADULTS WHO
SMOKE CIGARETTES, 2014
Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults—United States, 2005–2014. Morbidity and Mortality Weekly Report 2015;64(44):1233–40.
DISPARITIES AMONGST UTAH ADULTS WHO
SMOKE CIGARETTES, 2013 AND 2014
* These estimates have a relative standard error of
In 2010, data from 27 sites, representing 52%
of live births reported by CDC
23% of women reported smoking in the 3
months prior to pregnancy
54.3% reported that they quit smoking by the
last 3 months of pregnancy
Almost 11% reported smoking during the last
3 months of pregnancy
Almost 16% reported smoking after delivery
PREGNANCY AND SMOKING IN US, 2010
Centers for Disease Control and Prevention. Trends in Smoking Before, During, and After Pregnancy—Pregnancy Risk Assessment Monitoring System, United States, 40 Sites, 2000–2010. Morbidity and Mortality Weekly Report 2013;62(SS06)1–19 [accessed 2015 Dec 7].
UTAH PREGNANCY NUMBERS
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Smoked 3 months before pregnancy 14.3% 14.3% 13.8% 13.6% 11.5% 12.3% 10.2% 12.2% 10.6% 10.4% 13.1% 11.8% 11.3% Smoked last 3 months of pregnancy 6.2% 7.3% 7.7% 6.8% 3.9% 6.6% 5.1% 6.1% 5.3% 5.1% 5.9% 4.5% 4.0% Smoke now 9.3% 9.5% 10.1% 9.0% 7.7% 8.7% 7.3% 8.3% 7.6% 7.1% 8.0% 7.2% 6.3% 0% 5% 10% 15% 20%
Percent of Utah Women Who Smoked Before, During, and after
Pregnancy, 1999- 2011
Smoked 3 months before pregnancy Smoked last 3 months of pregnancy Smoke now
Smoking-related illness in the United States
costs more than $300 billion a year
$170 billion in direct medical care for adults
$156 billion in lost productivity
Secondhand smoke costs our economy $5.6
billion per year due to lost productivity
In 2012, $9.17 billion spent on advertising
and promotion of cigarettes
>$25 million daily
COST OF SMOKING
U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
Federal Trade Commission. Federal Trade
Commission Cigarette Report for 2012[PDF–308 KB]. Washington: Federal Trade Commission, 2015
ESTIMATED ANNUAL COST
OF SMOKING IN UTAH
TOBACCO PREVENTION AND CONTROL IN UTAH Fifteenth Annual Report, August 2015 http://www.tobaccofreeutah.org/pdfs/tpcpfy15report.pdf
In 1981, a Philip Morris report had the following to
say about tobacco & teenagers:
Nicotine addiction is a pediatric epidemic: nearly
90% of adult smokers started before the age of 18
NICOTINE ADDICTION & YOUTH
“Today’s teenager is tomorrow’s potential regular customer.
The smoking patters of today’s teenager are particularly
important to Philip Morris.”
-PM Industry Document, 1981
AAP. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. AAP; 2008. Benowitz NL, Goniewicz ML. JAMA. 2013;310:685-686.
From 2011 to 2014, conventional cigarette smoking
declined among middle and high school students
In 2014 2.5% of middle school students reported smoking
cigarettes in the past 30 days—a decrease from 4.3% in 2011
9.2% of high school students reported smoking cigarettes in
the past 30 days—a decrease from 15.8% in 2011
In 2014, 1.6% of middle school students and 5.5% of
high school students reported current use of
smokeless tobacco
CONCERN: These forms have been replaced with ENDS
(e-cigarette) use
NICOTINE AND YOUTH: BY THE NUMBERS
Centers for Disease Control and Prevention. Tobacco Use Among Middle and High School Students— United States, 2011–2014. Morbidity and Mortality Weekly Report, 2015;64(14):381–5
In Utah in 2014, 5.6% of individuals under the age of
18 reported that they currently smoke cigarettes
Preliminary results show tobacco use rates in
alternative schools are significantly higher than the
rates found in regular public schools:
27.5% of students in the alternative high school sample
reported current cigarette smoking compared to 3.4% of
students in regular public schools
NICOTINE ADDICTION AND UTAH YOUTH
TOBACCO PREVENTION AND CONTROL IN UTAH Fifteenth Annual Report, August 2015
http://www.tobaccofreeutah.org/pdfs/tpcpfy15report.pdf CDC Youth Online: High School YRBS
https://nccd.cdc.gov/youthonline/App/Results.aspx ?LID=UT
Electronic cigarette use among Utah youth nearly
doubled from 2013 (5.8%) to 2015 (10.5%) and is
more than twice as high as adult use
Nearly one quarter (22.9%) of Utah students in
grades 8, 10, and 12 have tried e-cigarettes
NICOTINE ADDICTION AND YOUTH: BY
THE NUMBERS (CONT’D)
TOBACCO PREVENTION AND CONTROL IN UTAH Fifteenth Annual Report, August 2015 http://www.tobaccofreeutah.org/pdfs/tpcpfy15report.pdf
YOUTH TOBACCO USE
BY PRODUCT TYPE (2015)
TOBACCO PREVENTION AND CONTROL IN UTAH Fifteenth Annual Report, August 2015 Tobacco Prevention and Control Program.
Prevention Needs Assessment Tobacco Questions, 2013 and 2015. Salt Lake City: Utah Department of Health
Secondhand Smoke (SHS) contains over 7,000 chemicals,
hundreds of toxins, and more than 70 carcinogens
30% increase in the chance of heart attack with long-term exposure
and a 20% increase in the chance of lung cancer
45,000 Americans die annually from secondhand smoke
From 2011–2012, 58 million nonsmokers in the United States
were exposed to secondhand smoke
Children who live in multi-unit housing have 45% higher cotinine
levels than children who live in single-family homes
2 out of 5 children ages 3 to 11—including 7 out of every 10
Black children—in the United States were exposed to
secondhand smoke regularly
During 2011–2012, more than 1 in 3 (36.8%) nonsmokers
who lived in rental housing were exposed to secondhand
smoke
SECONDHAND SMOKE: BY THE NUMBERS
SECONDHAND SMOKE
38.8% of Utah adults reported breathing SHS in the
past week at indoor or outdoor locations
In 2014, nearly 17,000 Utah children were exposed to
SHS inside their homes during the past week
TOBACCO PREVENTION AND CONTROL IN UTAH Fifteenth Annual Report, August 2015
Thirdhand Smoke is defined as the lingering
residue and odor that burned tobacco products
deposit onto clothing, hair and other surfaces
Within this residue, measurable amounts of
carcinogens are left on surfaces
Carcinogens can also even be detected in
children’s urine following exposure
No Numbers on this one
THIRDHAND SMOKE
Martins-Green M, et al. PloS one. 2014;9:e86391. , Thomas JL, et. al, Nicotine Tob Res, 2013; Hang B, et al., Mutagenesis 2013;28:381-91. Thomas JL, Cancer Epidemiol Biomarkers Prev. 2011;20:1213-21.
Electronic cigarette – e-cigarette, hookah stick
Electronic nicotine delivery device
Nicotine liquid – “Juice”
“Vaping”
Delivers more nicotine than regular cigarette
CDC and FDA studies have shown youth use of
e-cigarettes tripled from 2013-2014
Current e-cigarette use among high school students
1.5% in 2011
4.5 % in 2013
13.4 % in 2014
15.5% high schoolers and 11.8% of middle
schoolers were frequent users of e-cigarettes (20/30
days in past month)
Among 10th graders, 16.2% reported using an
e-cigarette and 7.2% reported using a traditional
cigarette
ELECTRONIC CIGARETTES ARE THE NEW
PATHWAY TO NICOTINE ADDICTION
U.S. Centers for Disease Control and Prevention (CDC), “Tobacco Use Among Middle and High School Students — United States, 2011- 2014,” Morbidity and Mortality Weekly Report (MMWR) 64(14):381-385, April 2015, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6414a3.htm?s_cid=mm6414a3_e
Since 2013, Utah youth use rates have doubled despite
the law prohibiting sales to minors under the age of 19
10% youth < 18yrs reported e cigarette use in past 30 days in
2015
5.8% reported use in 2013
Nearly one-third of Utah teens who used e-cigarettes in
the past 30 days have never tried a conventional
cigarette
In 2015, Utah teens used traditional tobacco at a rate of
3.4%
A recent Utah study showed that vape and tobacco
specialty stores are most likely to sell to teens
ELECTRONIC CIGARETTES ARE THE NEW
PATHWAY TO NICOTINE ADDICTION (UT)
Electronic Cigarettes in Utah http://www.tobaccofreeutah.org/pdfs/e-cig%20summary%202015.pdf
In 2014, 12.6% of adults had ever tried an e-cigarette
3.2 % of adults who had never smoked, 9.7% in age range
18-24 yrs.
About 3.7% of adults currently use e-cigarettes
Current cigarette smokers and former smokers who
quit smoking within the past year were most likely to
use e-cigarettes
Among current cigarette smokers who had tried to
quit smoking in past 12 months
>50% had ever tried an e-cigarette
20.3% were current e-cigarette users
WHAT ADULTS ARE USING
E-CIGARETTES?
.
Schoenborn CA, Gindi RM. Electronic cigarette use among adults: United States, 2014. NCHS data brief, no. 217. Hyattsville, MD: National Center for Health Statistics. 2015.
Schoenborn CA, Gindi RM. Electronic cigarette use among adults: United States, 2014. NCHS data brief, no. 217. Hyattsville, MD: National Center for Health Statistics. 2015.
Schoenborn CA, Gindi RM. Electronic cigarette use among adults: United States, 2014. NCHS data brief, no. 217. Hyattsville, MD: National Center for Health Statistics. 2015.
Nearly 60% of current e-cigarette users also smoke
cigarettes
Nearly 15% of current e-cigarette users have never
smoked a conventional cigarette
While adult e-cigarette use rates have risen sharply
in the past two years, cigarette smoking rates have
remained mostly unchanged
WHAT UTAH ADULTS ARE USING
E-CIGARETTES?
Electronic Cigarettes in Utah http://www.tobaccofreeutah.org/pdfs/e-cig%20summary%202015.pdf
May deliver Nicotine=Highly addictive
Few safety or advertising regulations
Marketed with potential for smoking cessation
Emissions
Lower toxins found than in a traditional cigarette, but
higher levels than what is found in a nicotine replacement
therapy product
Unknown what frequent, routine inhalation of propylene
glycol and flavoring agents will do to lung tissue
WHAT ARE THE KNOWN HEALTH
EFFECTS?
Benowitz NL, Goniewicz ML. JAMA. 2013;310:685-686. Goniewicz ML, et al. Tob. Control. 2014;23:133-139. Kosmider L, et al. Nicotine Tob Res. 2014;16:1319-26. 4Grana R, et al.
As of September 2015
USPTF does not support them as a cessation tool
They are not FDA approved
And…E-cigarettes may alleviate the desire to smoke cigarettes
and reduce consumption and/or enable short periods of
cessation
Cochrane review 2014
“Low grade evidence in 2 small trials” to reduce long term smoking
compared to sham e-cigs
May assist patients to “cut down” but low grade evidence to date
Note: Patches and gum differ from e-cigarettes in that they
are FDA regulated and administer low doses of nicotine slowly
into the body unlike e-cigarettes
ARE THEY A CESSATION AID?
Schepers JS. Electronic cigarettes: do they have a role in smoking cessation? J Pharm Pract. 2012;25(6):611–614. Cochrane Database Syst Rev. Electronic cigarettes for smoking cessation and reduction.
.2014;12:CD010216. Epub 2014 Dec 17.
http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions1
•
Association between current e-cigarette use and
conventional cigarette use among adolescents
Poisonings through ingestion, inhalation, or
absorption of nicotine liquid on the skin;
Child poisonings related to e-cigarettes increased sharply from
2011-2014
PEDIATRIC CONCERNS
Dutra LM, Glantz SA. JAMA Pediatrics.2014;168:610-617
TOBACCO PREVENTION AND CONTROL IN UTAH Fifteenth Annual Report, August 2015 http://www.tobaccofreeutah.org/pdfs/tpcpfy15report.pdf
Ask about “vaping” as you screen
Use evidence-based smoking cessation methods
“Smoking Cessation Guidelines do not recommend vaping or e cigs”
Recommend avoidance of smoked tobacco
“E-cigs and vaping reinforce the automatic habits of smoking and
may hinder quitting”
“E-cigs may deliver higher levels of nicotine to you more rapidly and
keep you hooked”
Follow results of e-cigarette clinical trials
WHAT SHOULD I BE SAYING TO MY
PATIENTS ABOUT THESE THINGS?
Schepers JS. Electronic cigarettes: do they have a role in smoking cessation? J Pharm Pract. 2012;25(6):611–614. Knorst et al. J Bras Pneumol. 2014 Sep-Oct; 40(5): 564–572.
Nicotine Causes
Dependence, body quickly requires
more and more for effect
Elevation in heat rate and blood
pressure
Vasoconstriction
Elevates respiratory rate
Jaw pain, worsen TMJ disorder esp.
oral forms
Tooth disorders
Headache
Nausea
Hiccups
Palpitations, arrhythmia
Flatulence, diarrhea
Insomnia
Chest discomfort
Contraindication or Cautions
Recent MI
CAD
Arrhythmias
Angina
Asthma
Peripheral vascular disease
Pregnancy
Insulin dependent DM
HTN
Hyperthyroidism
Pheochromocytoma
Renal impairment
NICOTINE SIDE EFFECTS
https://online.epocrates.com
HELPING PEOPLE QUIT
Ask,
Advise,
CLINICAL PRACTICE GUIDELINE FOR
TREATING TOBACCO USE AND DEPENDENCE
May 2008
Sponsored by
Agency for Healthcare Research
and Quality
National Cancer Institute
National Institute for Drug Addiction
National Heart, Lung, & Blood Institute
Robert Wood Johnson Foundation
Centers for Disease Control and
Prevention
Current billing codes
EHR tools and workflow tips
http://www.aafp.org/dam/AAFP/documents/patient_care/tob
acco/practice-manual.pdf
TOBACCO DEPENDENCE:
A TWO PART PROBLEM
Tobacco Dependence
Treatment should address the physiological
and the behavioral aspects of dependence.
Physiological
Behavioral
Treatment
Treatment
The addiction to nicotine
Medications for cessation
The habit of using tobacco
Nicotine polacrilex gum
Nicorette (
OTC)
Generic nicotine gum (OTC)
Nicotine lozenge
Commit (OTC)
Generic nicotine lozenge (OTC)
Nicotine transdermal patch
Nicoderm CQ
(OTC)
Nicotrol
(OTC)
Generic nicotine patches
(OTC, Rx)
Nicotine nasal spray
Nicotrol NS (Rx)
Nicotine inhaler
