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Steven A. Schroeder, MDProfessor of Medicine
University of California San FranciscoSan Francisco, California
Get Your Patients with HIV/AIDS to Stop Smoking Before it Kills Them
FORMATTED: 11/03/2015
New Orleans, Louisiana: December 15-17, 2015
Slide 2 of 56
Tobacco’s Deadly Toll
540,000 deaths in the U.S. each year* 4.8 million deaths world wide each year
--Current trends show >8 million deaths annually by 2030 42,000 deaths in the U.S. due to second-hand smoke
exposure 14 million in U.S. with smoking related diseases (60% with COPD) 42.1 million smokers in U.S. (76.9% daily smokers, averaging
14.2 cigarettes/day, 2013)
* Carter et al, NEJM, Feb 12, 2015
Slide 3 of 56
1955
1957
1959
1961
1963
1965
1967
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011
2013
0
10
20
30
40
50
60
TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2013
20.5%
15.3%
Trends in cigarette current smoking among persons aged 18 or older
Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2013 NHIS. Estimates since 1992 include some-day smoking.
68.8% want to quit
17.8% of adults are
current smokers
Male
Female
Per
cen
t
Slide 4 of 56Smoking Prevalence and Average Number of Cigarettes Smoked per
Day per Current Smoker 1965-2010
Source: Schroeder, JAMA 2012; 308:1586; *CDC/NCHS, National Health Interview Survey, 1997-March 2015, Sample Adult Core
Per
cent
/Num
ber
of C
igar
ette
s S
mok
ed D
aily
*January-March 2015: 15.3% prevalence!
Slide 5 of 56
Health Consequences of Smoking
U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General, 2010.
Cancers– Acute myeloid leukemia – Bladder and kidney– Cervical– Colon, liver, pancreas– Esophageal– Gastric– Laryngeal– Lung– Oral cavity and pharyngeal– Prostate (↓survival)
Pulmonary diseases– Acute (e.g., pneumonia)– Chronic (e.g., COPD)– Tuberculosis
Cardiovascular diseases– Abdominal aortic aneurysm– Coronary heart disease– Cerebro-vascular disease– Peripheral arterial disease– Type 2 diabetes mellitus
Reproductive effects– Reduced fertility in women– Poor pregnancy outcomes
(ectopic pregnancy, congenital anomalies, low birth weight, preterm delivery)
– Infant mortality; childhood obesity
Other effects: cataract; osteoporosis; Crohn’s; periodontitis; poor surgical outcomes; Alzheimer’s; rheumatoid arthritis; less sleep
Slide 6 of 56
Causal Associations with Second-hand Smoke
Developmental– Low birthweight– Sudden infant death
syndrome (SIDS)– Pre-term delivery-- Childhood depression
Respiratory– Asthma induction and
exacerbation– Eye and nasal irritation– Bronchitis, pneumonia, otitis
media, bruxism in children– Decreased hearing in teens
Carcinogenic– Lung cancer– Nasal sinus cancer– Breast cancer? (younger, premenopausal women)
Cardiovascular– Heart disease mortality
– Acute and chronic coronary heart disease morbidity
– Altered vascular properties
USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General.
There is no safe level of
second-hand
smoke.
Slide 7 of 56
Smoking and Behavioral Health: The Heavy Burden
240,000 annual deaths from smoking occur among patients with Chronic Mental Illness (CMI) and/or substance abuse
This population consumes 40% of all cigarettes sold in the United States-- higher prevalence-- smoke more-- more likely to smoke down to the butt
People with CMI die earlier than others, and smoking is a large contributor to that early mortality
Greater risk for nicotine withdrawal Social isolation from smoking compounds the social stigma
Slide 8 of 56
Smoking Imperils the HIV/AIDS Population
LGBT persons and those with substance use disorders have higher smoking rates
HIV/AIDS patients have higher smoking rates HIV patients who smoke have greater odds of
heart disease, cancer, CVA, and HIV-related infections than HIV patients who do not smoke
Slide 9 of 56
Nicotine enters brain
Stimulation of nicotine receptors
Dopamine release
Dopamine Reward PathwayPrefrontal
cortex
Nucleus accumbens
Ventral tegmental
area
Slide 10 of 56
Nicotine Addiction Tobacco users maintain a minimum serum
nicotine concentration in order to– Prevent withdrawal symptoms– Maintain pleasure/arousal– Modulate mood
Users self-titrate nicotine intake by– Smoking more frequently– Smoking more intensely– Obstructing vents on low-nicotine brand
cigarettes
Slide 11 of 56
Tools for Smoking Cessation
5As (Ask, Advise, Assess, Assist, Arrange) AAR (Ask, Advise, Refer) Quitlines NRT and other medications Counseling and behavioral change strategies Peer-to-peer intervention
Slide 12 of 56
Treatment
Persons with HIV, mental illnesses, and substance use disorders benefit from same interventions as general population
Combination of counseling and pharmacotherapy should be used whenever possible
Duration of treatment might be longer View failed quit attempt as a practice, not failure
Slide 13 of 56
Cognitive Strategies for Cessation
Review commitment to quit, focus on downsides of tobacco use
Reframe the way a patient thinks about smoking Distractive thinking Positive self-talks, “pep talks” Relaxation through imagery Mental rehearsal, visualization
Slide 14 of 56
Behavioral Strategies for Cessation (Avoiding Stimuli that Trigger
Smoking)
Stress – Anticipate future challenges– Develop substitutes for tobacco
Alcohol – Limit or abstain during early stages of
quitting Other tobacco users
– Stay away– Ask for cooperation from family and
friends
Slide 15 of 56
Behavioral Strategies for Cessation (Part 2)
Oral gratification needs – Use substitutes: water, sugar-free chewing
gum or hard candies Automatic smoking routines
– Anticipate routines and develop alternative plans, e.g., with morning coffee
Weight gain after cessation – Anticipate; use gum or bupropion; exercise
Cravings – Distractive thinking; change activities
Slide 16 of 56
PHARMACOTHERAPY
Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
Medications significantly improve success rates. * Includes pregnant women, smokeless tobacco users, light smokers, and adolescents.
“Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations* for which there is insufficient evidence of effectiveness.”
Slide 17 of 56
Pharmacologic Methods: First-line Therapies*
Three general classes of FDA-approved medications for smoking cessation: Nicotine replacement therapy (NRT)
-- nicotine gum, patch, lozenge, nasal spray, inhaler Partial nicotine receptor agonist
-- varenicline--? cytisine in the future
Psychotropics-- sustained-release bupropion
* Counseling plus meds better than either alone
Currently, no medications have an FDA indication for use in spit tobacco cessation.
Slide 18 of 56
Caveats About Cessation Literature Smoking should be thought of as a chronic condition,
yet drug treatment often short (12 weeks) in contrast to methadone maintenance
Great spectrum of severity and addiction; treatment should be tailored accordingly
Volunteers for studies likely to be more motivated to quit
Placebo and drug groups tend to have more intensive counseling than found in real practice world; and counseling is not a monolithic black box
Most drug trials exclude patients with mental illness
Slide 19 of 56
LONG-TERM (6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS
0
5
10
15
20
25
30
Nicotine gum Nicotinepatch
Nicotinelozenge
Nicotinenasal spray
Nicotineinhaler
Bupropion Varenicline
Active drugPlacebo
Data adapted from Cahill et al. (2012). Cochrane Database Syst Rev; Stead et al. (2012). Cochrane Database Syst Rev; Hughes et al. (2007). Cochrane Database Syst Rev
Per
cen
t q
uit
16.3 15.9
10.0 9.8
18.9
8.4
23.9
11.8
17.1
9.1
18.9
10.612.0
28.0
Slide 20 of 56
Quitlines and Behavioral Health
Do quitlines work for people with MI and/or SUD? Yes
Are they able to meet the demand? They are underused
Slide 21 of 56
Tips for Your Office
Referral forms to the quitline (1-800-QUITNOW) Carbon monoxide breathalyzer (cost about $500
plus disposal mouthpieces) One key question to ask: “When do you have your
first cigarette of the day?” Approach smoking as a chronic illness, just like
HIV/AIDS in 2015
Slide 22 of 56
Contact SCLC for Technical Assistance
Visit us online http://smokingcessationleadership.ucsf.edu
– CME/CE webinars– Fact sheets, toolkits, publications– Training resources and presentations– E-newsletter and listserv– Online ordering for 1-800-QUIT NOW cards
Call us toll-free 1-877-509-3786
Slide 23 of 56
The Electronic Cigarette*
Aerosolizes nicotine in propylene glycol solvent; e-cig products in evolution
Cartridges contain about 20 mg nicotine Safety unproven, but >cigarette smoke Probably deliver < nicotine than promised Unclear if help smokers quit Not approved by FDA My advice: avoid unless patient insists
* Cobb & Abrams. NEJM July 21, 2011; Fiore, Schroeder, Baker, NEJM Jan 23, 2014
Slide 24 of 56
Cigarette and E-Cigarette Use among High School Students, 2000-2014
Source: Youth Risk Behavior Survey