Assisting Adolescents and Adults to Stop Smoking TAFP C. Frank - - PowerPoint PPT Presentation

Assisting Adolescents and Adults to Stop Smoking

TAFP C. Frank Webber Lectureship Austin, Texas Friday – April 5, 2019 9:45 – 11:15 a.m.

Clare Hawkins, MD, MSc, FAAFP – Regional Medical Officer – Aspire Healthcare

Speaker Disclosure

• Dr. Hawkins has disclosed that he has no actual or

potential conflict of interest in relation to this topic.

Smoking Cessation Objectives

By completing this educational activity, the participant should be better able to:

• 1. Recognize the impact of tobacco use on

health.

• 2. Discuss the evidence for e‐cigarettes

and vaping on patient’s health.

• 3. Make office system changes to increase

cessation rates.

• 4. Practice counseling with stages of

change approach for smoking cessation and vaping.

• 5. Prepare an action plan to reach health

goals.

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Epidemiology in Adults

• 2017 record low to 14% U.S. Adults smoking
• Estimated 480,000 deaths annually attributed to tobacco
• 40% of smokers make an average of 2 quit attempts

annually

Rostron BL, Chang CM, Pechacek TF. Estimation of cigarette smoking‐attributable morbidity in the United States. JAMA Intern Med. 2014 Dec;174(12):1922‐8. Anthonisen NR, Skeans MA, Wise RA, Manfreda J, Kanner RE, Connett JE. Lung Health Study Research Group. The effects of a smoking cessation intervention on 14.5‐year mortality: a randomized clinical trial. Ann Intern Med. 2005;142(4):233‐239.

Epidemiology in Children and Adolescents

• 24.2% High School (3.69

million students) in 2011 and 27.1% in 2018

• 4.04 million students
• From 2017 to 2018 middle

school students increased

from 5.6% to 7.2%

CDC 2018 & Surgeon General

History

• Late recognition of connection between smoking and cancer
• Long battle with tobacco manufacturers (see The Emperor of All

Maladies: A History of Cancer, Siddhartha Mukherjee)

• Tobacco Settlement $$ (funding quit lines… and highways)
• Master Settlement Agreement, 1998
• Resurgence of aggressive techniques to recruit youth smokers
• International tobacco promotion

Physiology

• Inhalation of tobacco smoke and is rapidly absorbed in pulmonary

venous circulation then enters arterial circulation to travel directly to the brain

• Strongly felt rush (highly efficient route of delivery)
• Smoking process and rapid reinforcement allows for precise dosing
• Can achieve desired effect without toxicity
• Smoking improves concentration, reaction time, and performance of certain

tasks

• Activation of alpha4Beta2 neuronal nicotinic acetylcholine receptors

Benowitz NL, Nicotine Addiction. N Engl J Med. 2010 June 17 362(24): 2292‐2303.

DOPAMINE!

• Activation results in Dopamine release signaling
• Pleasurable experience resulting in reinforcing smoking
• Mesolimbic area, corpus striatum, and frontal cortex
• Ventral tegmental area of midbrain and shell of nucleus accumbens
• Glutamine release facilitating both Dopamine and GABA which

inhibits dopamine though long‐term exposure results in GABA desensitization leaving dopamine unbalanced

• Hypocretins, neuropeptides in the lateral hypothalamus also

regulate the stimulatory effects of nicotine on reward centers

MAOI, Tolerance and Withdrawal

• Acetaldehyde in cigarette smoke inhibit monoamine oxidase, (MAO A

and B) contributing to the addictiveness of smoking by reducing the metabolism of dopamine

• Neuroadaptation (tolerance) develops by increasing binding sites in

brain, and desensitization (closure of the receptor) plays a role in tolerance and dependence: With craving and withdrawal beginning earlier

• With near complete saturation of alpha4Beta2, smokers are probably

attempting to avoid withdrawal symptoms by regularly smoking

• Withdrawal: Anxiety, stress, craving, irritability, depressed mood,

restlessness, Anhedonia. (Cascade of corticotropin releasing factor, CRF which precipitates relapse)

Conditioning

• Conditioning: Urge to resume smoking

long after withdrawal symptoms dissipate

• Cues can trigger relapse
• After a meal, with a cup of coffee, or an

alcoholic drink

• Smoking with friends
• Manipulation of smoking materials
• Taste, smell and feel of smoke in the throat
• Light smokers (<5/d) and occasional

smokers have difficulty quitting

• Dependence with different

pharmacodynamics from heavier smokers

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Genetics

• High degree of heritability of cigarette

smoking (>50%)

• Candidate genes coding for nicotine‐

receptor subtypes, dopamine receptors, and dopamine transporters, GABA receptors, opiate and cannabinoid

• receptors. (Also coding for cell adhesion and

extracellular matrix molecules common with

• ther addiction)
• Genome‐wide association alpha5/alpha3/Beta4 nicotinic cholinergic receptor gene complex on chromosome 15
• Neural plasticity and learning are key determinants of individual differences in vulnerability

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Nicotine Addiction, Youth and Mental Health

• 80% of smokers begin smoking by 18 years of age
• 2/3 of young people try cigarette smoking and only 20‐25% of them

become dependent daily smokers

• Peer and parental influences
• Behavioral problems, (poor school performance)
• Personality characteristics (rebelliousness, risk taking, depression and anxiety)
• Highly prevalent in persons with mental illness or other substance‐use

disorders

• Likely a shared genetic predisposition including capacity for nicotine to

relieve psychiatric symptoms

Lynch, BS, Bonnie RJ, Growing up tobacco free – preventing nicotine addiction in children and youths. Washington, DC: National Academy Press; 1994. The nature of nicotine addiction; p.28‐68.

Women

• Smoking behavior in women is more

strongly influenced by conditioned cues and negative affect

• Men are more likely to smoke in

response to pharmacologic cues, regulating intake of nicotine more precisely than women

• Women metabolize nicotine more

quickly

• Increased susceptibility to addiction and

more difficulty quitting

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FIVE As

Ask Advise Assess Assist Arrange

https://www.aafp.org/patient‐care/public‐health/tobacco‐nicotine/toolkit.html.

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• 1. Ask
• Office systems should ensure that all

tobacco users are identified

• Smoking status should be documented at

every visit

• Promoting cessation appears to increase

patients’ satisfaction with their visit, even among smokers not yet motivated to quit

• Including it as a vital sign may remind the

physician

• “Have you ever been a smoker or used other

tobacco products? Do you use tobacco now? How much?”

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• Unambiguous support for

smoking cessation should be expressed by the physician, and the benefits of quitting should be discussed

• Advice to patients should be clear

(direct expression of the need for smoking cessation)

• Strong: Highlighting the importance
• f cessation
• Personalized: Linking the patients

health goals to cessation

• 2. Advise

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Teachable Moments

• AdobeStock. License 65454027
• New patient visits
• Annual physicals
• Well‐child visits (e.g., discuss smoking

in the home and car)

• Women’s wellness exams
• OV for tobacco influenced diseases:

i.e., upper respiratory conditions, diabetes, hypertension, asthma

• Follow‐up visits after hospitalization

for a tobacco‐related illness or the birth of a child

• A recent health scare

How Bad are Your Lungs? Tell Them Their “Lung Age”?

• 52 yo patient with Spirometry

showing FEV1 value at the level

• f a nonsmoking 75 year old
• Discussion of “lung age”

prompted higher quit rate at

• ne year even if lung age not

reduced

• 13.6 vs. 6.4 in the control group

who only received a number

Parkes G, Greenhalgh T, Griffin M, Dent R. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomized controlled trial. BMJ. 2008;336(7644):598‐600.

But I’m Going to Gain Weight?

• Weight gain is a major concern (or rationalization) of those who

are contemplative

• Modest weight gain carries less risk than ongoing smoking
• Bupropion, fluoxetine, NRT and varenicline reduce post cessation

weight gain while using the medication. Although this effect was not maintained one year after stopping smoking, the evidence is insufficient to exclude a modest long‐term effect.

Farley AC et al. Interventions for pre‐venting weight gain after smoking cessation. Cochrane Database Syst Rev. 2012 Jan 18;1:CD006219.

Drug Interactions

• Induction of cytochrome P450 (CYP) 1A1, CYP1A2 and possibly

CYP2E1, CYP1A1

• Caffeine, tacrine, imipramine, haloperidol, pentazocine,

propranolol, flecainide and estradiol. Cigarette smoking results in faster clearance of heparin

• Lesser magnitude of blood pressure and heart rate lowering

during treatment with beta‐blockers

• Less sedation from benzodiazepines and less analgesia from some
• pioids

Zevin S, Benowitz, NL. Drug interactions with tobacco smoking. An update. Clin Pharmacokinet. 1999;36(6):425‐38. Kroon LA. Drug interactions with smoking. Am J Health System Pharm. 2007;64(18):1917‐21.

• 3. Assess
• Willingness to quit and barriers to quitting should be assessed as

well as smoking history and current level of nicotine dependence

• Patient should be asked about their timeline for quitting and

previous attempts

• “Have you ever tried to cut back on or quit smoking?”
• ”Are you willing to quit smoking now?"
• ”What keeps you from quitting?
• “How soon after getting up in the morning do you smoke?”
• 2/3 of smokers want to quit
• Only 1/3 make a quit attempt using EBM methods

”Are you willing to quit smoking now?"

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The Five “Rs”

• 1. Relevance: Why is quitting relevant to this patient? For example,

maybe he or she has had a personal health scare, such as a recent heart attack, or has a child who has asthma

• 2. Risk: Ask the patient to list negative effects of their tobacco use.

These may include short‐term risks, long‐term risks, and environmental damage

• 3. Rewards: Ask the patient to list benefits of quitting. These may

include being healthier, saving money, setting a good example,

• r having better self‐esteem

Baird M, Blount A, Brungardt S, et al. Joint principles: integrating behavioral health care into the patient‐centered medical home (www.annfammed.org). Ann Fam Med. 2014;12(2):183‐85.

The Five “Rs” Continued

• 4. Roadblocks: Ask the patient to identify barriers to quitting. Then, talk

about ways to address these barriers. For example, if a patient is worried about withdrawal symptoms, ease his or her fears by describing medication options that can help.

• 5. Repetition: The health care team should repeatedly follow up with the

patient, keeping in mind that it may take repeated attempts to quit, especially for patients with a behavioral health disorder

Baird M, Blount A, Brungardt S, et al. Joint principles: integrating behavioral health care into the patient‐centered medical home (www.annfammed.org). Ann Fam Med. 2014;12(2):183‐85.

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Precontemplative Patients

• Unaware of the need to change
• May overestimate the costs of change and

underestimate the benefits

• Reluctance: (Does not want to consider

change, inertia)

• Rebellion: (Does not like being told what

to do), resignation (overwhelmed and demoralized by the idea of change)

• Rationalization: (Understands the

consequences of the behavior, but denies that they apply to him or herself)

Prochaska JO, Norcross JC. Stages of change. Psychotherapy. 2001; 38(4):443‐448.

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Stages of Behavior Change: Transtheoretical Model

Stage Description Comments Precontemplation No intention to take action within the foreseeable future (next six months) Possibly unaware of the need to change; may underestimate the benefits; consider reluctance, inertia, rebellion, resignation, rationalization Contemplation Considering change within the next six months Ambivalent about change: perceives that cost equal benefits Preparation Planning to take action within the next month May have already made steps toward change;

• ften concerned about failure

Action Actively changing (first six months of new behavior) Needs vigilance to prevent relapse and encouragement to keep up the momentum Maintenance More than six months since behavior change May benefit from reminders about high‐risk situations

Cahill K, Lancaster T, Green N. Stage‐based interventions for smoking cessation. Cochrane Database Syst Rev. 2010;(11):CD004492. Lai DT, Cahill K, Qin Y, Tang JL. Motivational interviewing for smoking cessation. Cochrane Database Syst Rev. 2010;(1):CD006936. Prochaska J. DiClemente C. Stages and processes of self‐change of smoking. Toward an integrative model of change. J Consult Clin Psychol. 1983; 51(3):390‐395.

SET A QUIT DATE

Have them choose a meaningful date Anniversary – date of a marriage ‐ Of a relative’s death ‐ Or…January 1

• 4. Assist
• Offer support and additional resources
• Help patients to anticipate difficulties and encourage them to prepare

their social support systems and their environment for the impending change

• WITHDRAWAL: Peak first week and can last 2‐4 weeks
• NRT can be helpful as they gradually decrease nicotine
• Smokers should be advised to decrease nicotine intake
• DEPRESSION
• More likely to have a depressive episode and this can subvert quit attempt
• May trigger depression if past history of depression and consider bupropion

Larzelere, M, Promoting Smoking Cessation. Am Fam Physician. 2012;85(6):591‐598.

Nicotine

• Gum OTC
• Lozenges OTC
• Nasal Spray (Rx)
• Inhaler (Rx)
• Nicotine Patch (Rx or OTC)
• “Patch Plus”: New

Guideline Patch plus Lozenge

Fiore MC, Jaén CR, Baker TB, et al. Clinical practice guideline: treating tobacco use and dependence: 2008 update. https://www.ncbi.nlm.nih.gov/books/NBK63952/. Accessed January 17, 2019.

• Dr. Hawkins purchased AdobeStock license 204934165

AAFP Toolkit. Pharmacologic‐quit guide. https://www.aafp.org/patient‐care/public‐health/tobacco‐nicotine/toolkit.html. Accessed January 18, 2019

Nicotine Delivery

• Patches: 7 mg, 14 mg and 21 mg
• For 1ppd smoker 21 x 2 weeks, 14mg x 2 weeks and 7 mg for 6

weeks

• NRT Nasal Spray:
• 1‐2 doses/hour (8‐40 doses/day); one dose = one spray in each

nostril (each spray delivers 0.5 mg nicotine)

• NRT Oral Inhaler
• 6‐16 cartridges/day; initially use 1 cartridge q 1‐2 hours (best

effects with continuous puffing for 20 minutes)

Are E‐Cigarettes a Helpful Nicotine Replacement?

• 1‐year abstinence rate was 18.0% in the

e‐cigarette group

• 1‐year abstinence rate was 9.9% in the

nicotine‐replacement group

• But much higher rate use of e‐cigarettes

at the one‐year mark

• Would e‐cigarette use be a substitute rather

than an avenue for abstinence

• Long‐term effect of e‐cigarette uncertain

Hajek P et al. A Randomized Trial of E‐Cigarettes versus Nicotine‐Replacement Therapy. N Engl J Med. 2019; 380:629‐637. Dinakar C O’Connor GT, The Health Effects of Electronic Cigarettes. N Engl J Med. October 16 2016; 375:1372‐1381.

Bupropion

• Begin dosing 1‐2 weeks before quit date
• 150 mg AM x 3 days as tolerated
• 150 mg po bid
• Contraindications: Head injury, seizure disorder, MAO inhibitor

therapy

Ali A, Kaplan CM, Derefinko KJ, Klesges RC. Smoking cessation for smokers not ready to quit: meta‐analysis and cost‐effectiveness analysis. Am J Prev Med. 2018;55(2):253‐262. doi:10.1016/j. amepre.2018.04.021. Tonstad S, Farsang C, Klaene G, et al. Bupropion SR for smoking cessation in smokers with cardiovascular disease: a multicentre, randomised study. Eur Heart J. 2003;24(10):946‐955.

Varenicline

• 6 months abstinence: Varenicline 33.2% compared with 23.4% for

the nicotine patch and 24.2% for bupropion

• Quit Date Method: 0.5 daily 3 days then 0.5 bid four days then

1mg bid starting on quit date and continue 12 weeks

• Gradual Method
• 44% prefer to quit through reduction of cigarettes smoked
• 68% would prefer medication assistance
• Same dose ramp up 0.5 to 1 bid but reduce smoking 50% month one,

then 75% and abstinent by 3 months

Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta‐analysis. Cochrane Database Syst Rev. 2013;(5):CD009329. Fiore MC, Jaén CR, Baker TB, et al. Clinical practice guideline: treating tobacco use and dependence: 2008 update. https://www.ncbi.nlm. nih.gov/books/NBK63952/. Accessed Jan 17, 2019. Ebbert JO et al. Effect of Varenicline on Smoking Cessation Through Smoking Reduction: A Randomized Clinical Trial. JAMA. 2015; 313(7):687‐694.

Varenicline OTC?

• Research has shown safety for varenicline in patients with

behavioral health disorders*

• FDA removed the psychiatric warning from both varenicline

and bupropion in 2016

• Evidence of excess Cardiovascular Risk related to varenicline

refuted

• Varenicline can be used on a modified schedule

*Anthenelli RM, Benowitz NL, West R, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without

psychiatric disorders (EAGLES): a double‐blind, randomised, placebo‐controlled clinical trial. Lancet. 2016;387(10037):2507‐2520.

Prescriptions and Coronary Artery Disease

• Smoking cessation substantially

reduces risk of heart disease

• Initial concerns about supplemental

nicotine and vasospasm or even pro‐ thrombosis

• No longer a concern
• Benefit exceeds risk

Curry SC, Kashani JS, LoVecchio F, Holubek W. Intraventricular conduction delay after bupropion overdose. J Emerg Med. 2005;29(3):299‐305. Meine, Trip J. et al. Safety and effectiveness of transdermal nicotine patch in smokers admitted with acute coronary syndromes. American Journal of Cardiology. 95(8), 976 – 978.

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Prescriptions and Pregnancy

• USPSTF recommends that all Pregnant Women be screened* A
• Use of pharmacotherapy has inconsistent evidence
• Nicotine D
• Bupropion and Varenicline C
• USPSTF. Smoking in Adults. Ann Intern Med. 2015;163(8):622‐634.

Behavioral & Pharmacotherapy Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Women: Recommendation Statement. Am Fam

• Physician. 93(10) 860A‐G.

A = consistent, good‐quality patient‐oriented evidence B = inconsistent or limited‐quality patient‐oriented evidence C = consensus, disease‐oriented evidence, usual practice, expert opinion, or case series www.aafp.org/afpsort.xml

Second‐Line Therapies

• Clonidine and nortriptyline also have demonstrated

effectiveness in clinical trials for smoking cessation*

• Not a universal finding for antidepressants**
• Benzodiazepines provide no value
• MAOI inhibitors?

*Fiore MC, Jaen CR. Baker TB, et al. Treating tobacco use and dependence 2008 update Rockville Md; Public Health Service. 2008, http://wwwsurgeongeneral.gov/tobacco/treating_tobacco_use08.pdf. Accessed January 15, 2019. **Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev. 2007;(1):CD000031.

Complimentary Therapies

Therapy Comments Acupuncture Acupuncture, acupressure, laser acupuncture, and electroacupuncture, Cochrane found inconsistent evidence Exercise Small heterogenous studies provide little evidence (but may assist in weight loss) Hypnotherapy Cochrane found lack of evidence Internet‐based interventions www.smokefree.gov. 20 RCT did not find conclusive evidence

• f benefit but may be an adjunct to other strategies (by

providing tailored messages and repeated automated contacts) Telephone quit lines 800‐QUIT‐NOW Physician encouragement to use quit lines has 2‐3x greater effect on smoking cessation than counseling alone in the primary care setting

Larzelere, M. Promoting Smoking Cessation. Am Fam Physician. 2012;85(6):591‐598.

Employee Programs

• Higher insurance premiums
• Financial Incentives: Financial incentive programs of

approximately $800 tripled the rates of abstinence through 6 months*

• Financial Incentives plus smoking aids**

*Volpp KG, Troxel AB, Pauly MV, et al. A randomized, controlled trial of financial incentives for smoking cessation. N Engl J Med. 2009;360:699‐709. *Halpern SD, French B, Small DS, et al. Randomized trial of four financial incentive programs for smoking cessation. N Engl J Med. 2015;372:2108‐17. **Scott D, et al. A Pragmatic Trial of E‐Cigarettes, Incentives, and Drugs for Smoking Cessation. N Engl J Med. 2018;378:2302‐10. DOI: 10.1056/NEJMsa1715757.

Can Electronic Cigarettes Help Quit?

• USPSTF inconclusive evidence
• Free smoking cessation aids and financial incentives help

while E cigarettes do not*

• More later…

Scott D, et al. A Pragmatic Trial of E‐Cigarettes, Incentives, and Drugs for Smoking Cessation. N Engl J Med. 2018;378:2302‐10. DOI: 10.1056/NEJMsa1715757.

• 5. Arrange (Follow‐up)
• Evidence for counselling by physician, nurse counselor
• Q 2 weeks?
• Better success rates after 4 sessions
• On‐Line only smoking resources not shown to be helpful
• Trusted physician + Quit line or counseling effective
• Reimbursement codes (see AFP toolkit)
• Meaningful use credit for integration with Quit Lines

(automatic order and referral)

Stead LF, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database Syst Rev. 2006;(3):CD002850.

Adolescent Smoking

Youth and Smoking

• 5.6 million of today’s Americans younger than 18 will die early from a

smoking‐related illness. That’s about 1 of every 13 Americans aged 17 years or younger alive today*

• Youth may be sensitive to nicotine and that teens can feel dependent on

nicotine sooner than adults.

• Mother’s smoking during pregnancy may increase the likelihood that her
• ffspring will become regular smokers
• Lack of skills to resist
• Lack of parental support
• Poor academic achievement & low self esteem
• Exposure to advertisement

*CDC. Youth and Tobacco. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm. Accessed 1/17/19.

Adolescent Smoking Epidemiology

• Ninety percent of adult smokers began smoking as adolescents or

preadolescents*

• Smoking rates among high school students peaked 1976 at 40%,

tapered in 1980s and peaked again 1997**

• Tobacco Master Settlement Agreement (MSA), banned teen

tobacco advertisements and cigarette taxes increased

• Twelfth grade smoking rate 23% in 2005 still at 24% in 2018
• Stress, psychiatric disorders (i.e., ADHD and depression) linked to

increased smoking rates

*Centers for Disease Control and Prevention. Cigarette use among high school students – United States, 1991‐2005. MMWR Morb Mortal Wkly Rep. 2006;55(26):724‐726. **Rosen IM , Maurer DM Reducing Tobacco Use in Adolescents. Am Fam Physician. 2008;77(4):483‐490, 491‐92.

Tobacco Use Among High School Students 2017

*CDC. Youth and Tobacco. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm. Accessed 1/17/19.

Novel Tobacco Products

• Smokeless Tobacco: Dip, chew, etc.
• High school athletes are more likely to use smokeless tobacco than their

peers who are non‐athletes

• Hookah: Inhaled through traditional water filter device, single or

group

• Bidis: Small, thin, hand‐rolled cigarettes from India and SE Asia
• Tobacco wrapped in a tendu or temburni leaf (plants native to Asia)
• May be secured with a colorful string at one or both ends
• Can be flavored (e.g., chocolate, cherry, mango) or unflavored
• Kreteks: Imported from Indonesia with cloves, tobacco and other

additives

Community Level Interventions

• Higher costs for tobacco products (for example, through increased

taxes)

• Prohibiting smoking in indoor areas of worksites and public places
• Raising the minimum age of sale for tobacco products to 21 years,

(and enforcement)*

• TV and radio commercials, posters, and other media messages

targeted toward youth to counter tobacco advertisements

• Community programs and school and college policies and

interventions that encourage tobacco‐free environments and lifestyles

• Community programs that reduce tobacco advertising, promotions,

and availability of tobacco products

USB Devices: “Flashy” but Discreet

• The rise in e‐cigarette use during 2017–2018 is likely

because of the recent popularity of e‐cigarettes shaped like a USB flash drive, such as JUUL; these products can be used discreetly, have a high nicotine content, and come in flavors that appeal to youths

• FDA recently issued 1300 warning letters and

monetary penalties to retailers

• Blu, JUUL, Logic, MarkTen XL, and Vuse

Children and E Cigarettes “Smoking Trainers”

• E‐cigarettes entered the U.S. marketplace around 2007
• Since 2014, they have been the most commonly used tobacco

product among U.S. youth

• E‐cigarette use among U.S. middle and high school students

increased 900% during 2011‐2015

• Current e‐cigarette use increased 78% among high school students

during the past year, from 11.7% in 2017 to 20.8% in 2018*

• Enforcement of age ban is lax and purchases on‐line

*Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the Field: Increase in use of electronic cigarettes and any tobacco product among middle and high school students – United States, 2011‐2018. MMWR Morbidity & Mortality Weekly Report. 2018; 67(45):1276‐1277. Ramamurthi D, Chau C, Jackler RK. JUUL and other stealth vaporisers: hiding the habit from parents and teachers. Tob Control. 2018. Epub ahead of print. doi: 10.1136/tobaccocontrol‐2018‐054455. King BA, Gammon DG, Marynak KL, Rogers T. Electronic Cigarette Sales in the United States, 2013‐2017. JAMA. 2018;320(13):1379‐1380.

E‐Cigarettes Jerome Adams Surgeon General Issues an Advisory

“ I am emphasizing the importance of protecting our children from a lifetime of nicotine addiction and associated health risks by immediately addressing the epidemic of youth e‐cigarette use. The recent surge in e‐cigarette use among youth, which has been fueled by new types of e‐cigarettes that have recently entered the market, is a cause for great concern. We must take action now to protect the health of our nation’s young people.”

https://e‐cigarettes.surgeongeneral.gov. Accessed January 17, 2019.

Flavor

• Flavorings in tobacco products can

make them more appealing to youth*

• 73% of high school students and

56% of middle school students who used tobacco products in the past 30 days reported using a flavored tobacco product during that time (2014)**

*Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the Field: Increase in use of electronic cigarettes and any tobacco product among middle and high school students – United States, 2011‐2018. MMWR Morbidity & Mortality Weekly Report. 2018; 67(45):1276‐1277. **Ambrose BK, Day HR, Rostron B, et al. Flavored Tobacco Product Use Among US Youth Aged 12‐17 Years, 2013‐2014. JAMA. 2015;314(17):1871‐1873.

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Menthol

• 11/2018 Scott Gottlieb, FDA Commissioner banned flavored

“represent one of the most common and pernicious routes by which kids initiate on combustible cigarettes”

• Which “disproportionately and adversely affect underserved

communities”

• The menthol exemption reflected the tobacco industry’s

power to protect its lucrative menthol market

• Brown & Williamson 1962

Wailoo K. The FDA’s Proposed Ban on Menthol Cigarettes. NEJM. 2019; 380:995‐997.

Cannabis and E‐Cigarettes

• Edible and vaporized cannabis that might appeal to youth

and be associated with polyuse*

• Users of E‐cigarettes were approximately three times more

likely to use cannabis products as well**

• Both Cannabis and tobacco are presented to a vulnerable

developing brain with consequences related to addiction and ensuing behavioral health and IQ

*Peters EN, Prevalence and Sociodemographic Correlates of Adolescent Use and Polyuse of Combustible, Vaporized, and Edible Cannabis Products. JAMA Netw Open. 2018; 1(5):e182765. doi: 10.1001/jamanetworkopen.2018.2765. **Trivers KF, Phillips E, Gentzke AS, Tynan MA, Neff LJ. Prevalence of Cannabis Use in Electronic Cigarettes Among US Youth. JAMA Pediatrics. 2018;172(11):1097‐1099.

Public Health Consequences of E‐Cigarettes

• Unknown toxins in propellants
• Although various forms of battery‐powered “electronic nicotine

delivery systems” (ENDS) devices have existed for more than a decade, their popularity, especially among youth, has increased in the past 5 years

• 7,000 harmful combustible chemicals which are in cigarettes are

not in ENDS

• Are they an “initiation pathway” of youth to smoking combustible

tobacco cigarettes?

National Academies of Sciences, Engineering, and Medicine. 2018. Public Health Consequences of E‐Cigarettes. Washington, DC: The National Academies Press. https://doi.org/10.17226/24952.

AAFP Smoking Cessation Resources

https://www.aafp.org/patient‐care/public‐health/tobacco‐nicotine/toolkit.html. Accessed 1/17/2019.

Tobacco Quitting Patterns

• 70% of smokers wat to quit, lower among those over 65,

Medicare or military

• Less educated, less interested in quitting
• 52% made a quit attempt for more than one day
• Private health plan 7.8%, Medicaid 4.6% or no health plan 3.6%
• 30% used a prescription to stop smoking
• Patch 15%, varenicline 11%, nicotine gum or lozenge 9%,

bupropion 3% and nicotine spray 1%

Centers for Disease Control and Prevention. Quitting smoking among adults—United States, 2001‐2010(cdc.gov). Morb Mortal Wkly Rep. 2011;60(44);1513‐19.

Systems Based Practice: Quality Assurance Evaluate your Office

• 1. Does your office currently

identify & document tobacco use?

• 2. How does your office

communicate the importance

• f quitting?
• 3. How does your office help

patients quit?

• 4. What systems do you have in

place?

Patient Visit Flow

• Visual cues
• MA asks and prompts

clinician

• Clinician Advises and Assesses
• MA or other does counseling
• r connects with counseling

system

• Patient schedules follow‐up

Winnable Battles

• Recognition and management of

unhealthy behaviors

• Transforming primary care

practices

• Tobacco use, obesity, unhealthy

diet, and inactivity account for 65% of deaths and 35% of years of life lost

• National Ambulatory Survey of

Screening

• 24% of ambulatory visits in 2010

were unscreened for tobacco

Nichols J & Bazemore A. Winnable Battles: Family Physicians Play an Essential Role in Addressing Tobacco Use and Obesity. Am Fam Physician. 2014 Jun 1;89(11):872.

TOBACCO OBESITY

Quit Lines: (1‐800‐QUIT‐NOW)

• https://www.naquitline.org/
• The North American Quit‐line Consortium (NAQC) is an

international, non‐profit membership organization based in Phoenix, Arizona. NAQC seeks to promote evidence‐based quit‐ line services across diverse communities in North America

• Quit‐lines are telephone‐based tobacco cessation services that

help tobacco users quit. Today, residents in all 10 provinces and two territories in Canada, Mexico, and all 50 U.S. states, Puerto Rico, Guam, and the District of Columbia have access to quit‐line services

Summary Recommendations Eh?

• All adults should be screened routinely for tobacco use. A
• All smokers should be encouraged to quit at every clinical
• contact. A
• Motivational interventions should be used with patients wo are

not yet ready to quit smoking. A

• Physicians should encourage appropriate patients to use

effective medications for treatment of tobacco dependence to improve quit rates. A

A = consistent, good‐quality patient‐oriented evidence B = inconsistent or limited‐quality patient‐oriented evidence C = consensus, disease‐oriented evidence, usual practice, expert opinion, or case series www.aafp.org/afpsort.xml

Summary Recommendations, Continued

• Heavy smokers should be encouraged to use higher dosages of a

nicotine replacement therapy, or more than one form (“patch plus” regimen). B

• Pregnant smokers should be offered person‐to‐person

psychosocial interventions that exceed minimal advice to quit. B

• Sustained‐release bupropion or a nicotine replacement therapy

(particularly gum and lozenges) may be more appropriate for smokers who are concerned about weight gain after quitting. C

A = consistent, good‐quality patient‐oriented evidence B = inconsistent or limited‐quality patient‐oriented evidence C = consensus, disease‐oriented evidence, usual practice, expert opinion, or case series www.aafp.org/afpsort.xml

Adolescent Smoking Evidence‐Based Interventions

• Screening for tobacco use in adolescents is recommended. B
• Tobacco cessation should be offered regularly using the 5‐A
• method. C
• Nicotine replacement therapy is recommended for adolescents

who meet criteria for tobacco dependence. B

A = consistent, good‐quality patient‐oriented evidence B = inconsistent or limited‐quality patient‐oriented evidence C = consensus, disease‐oriented evidence, usual practice, expert opinion, or case series www.aafp.org/afpsort.xml

Rosen IM, Maurer DM. Reducing Tobacco Use in Adolescents. Am Fam Physician. 2008;77(4):483‐490, 491‐92.

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