Good
Morning!
Welcome to
DAY 3
Were you able to complete the Values
Check #2 exercise last night?
a. Yes
b. No
c. I meant to, but was busy
doing other things.
2
Values Exercise # 2
Choose the answer closest to yours :
“Women smoke because _______”?
a.
b.
c.
d.
e.
4
They think it’s feminine
They want to control their weight
They love to smoke
It helps their stress levels
Other
Values Exercise # 2
Choose the answer closest to yours :
“Cardiovascular disease is caused
by _________”?
a.
b.
c.
d.
e.
5
Lack of exercise
Genetics
Smoking- no matter how much
Pollution
Other
Specific
Populations
and Tobacco
Use
Why Focus on Specific Populations?
•
•
•
•
•
•
8
Mental health
issues
Medical issues
Addictions
Gambling disorders
People who are
homeless or
underhoused
Older Adults
•
•
•
•
•
•
•
LGBTTTIQQ persons
Youth
Pregnant women
Incarcerated
individuals
Military recruits
Ethno-cultural groups
Aboriginal Persons
I have, or my organization has, cessation
services available for specific populations.
a. We are structured to be
accessible to a range of
populations.
b. We are accessible to a few
specific populations on an asneeded basis.
c. I am not sure what is available.
d. Limited cessation services are
available for specific populations.
9
Small Group Discussion
•
•
•
10
At your tables, please share your
experiences providing cessation services to
specific populations…..
What are some key considerations?
What questions to do you have?
Introduction
•
•
•
•
•
Historical perspective
Barriers to tobacco control
Associations: complex
Understanding remains incomplete
Association is:
– robust, reproducible, and clinically
significant
11
1.
2.
3.
4.
5.
Joseph et al., 2004
Masterson & O’Shea, 1984
Zuckermann & Kuhlman, 2000
Brandt & Gardner, 2000
Els, Kunyk, 2008.
In which type of disorder would we see
the highest rate of smoking prevalence?
a.
b.
c.
d.
e.
12
Anxiety disorder
Major depression
Bi-polar disorder
Schizophrenia
Personality disorders
Prevalence of Smoking in Psychiatric &
Substance Use Disorders
Psychiatric
disorders
Substance use
disorders
Smoking prevalence (%)
100
80
60
40
20
0
Clinical group
13
SZ, schizophrenia; BPD, bipolar disorder; MDD, major depressive
disorder; PD, panic disorder; OCD, obsessive-compulsive disorder;
PTSD, post-traumatic stress disorder
Kalman et al (2005) Am J Addict 14(2): 106-123
Non-psychiatric/substance use disorders
Youth & Smoking:
There is no significant difference between the
number of teenage males and teenage females
who smoke
a. True
b. False – Significantly more
teenage females smoke
c. False – Significantly more
teenage males smoke
14
Youth and Smoking
•
Smoking youth aged 15-19: 14%
– Lowest rate recorded since Health Canada first
(CTUMS, 2010 Wave 1)
–
–
–
–
began recording prevalence
→ 13% males, 14% females reported smoking
8% reporting daily smoking
6% occasional smoking
Average 11.6 cigarettes per day
25% purchased discount-brand cigarettes, 19%
from First Nations' reserve, 5% that may have
been smuggled (CTUMS, 2009 Annual Results)
CTUMS, 2010, Wave 1 Results – February-June
15
Young Adult Male Smoking: 20-24 Years of Age
•
24.3% are Current Smokers
 has consumed 100 cigarettes in his/her life and has
smoked within the last 30 days
•
16.5% are Daily Smokers
 has consumed 100 cigarettes in his/her life and has
smoked daily for the last 30 days
•
68.7% are Never Smokers
 Someone who has not smoked in the last 30 days
•
75.7% are Non Smokers
 Someone who has never smoked 100 cigarettes or
more in his life
16
Canadian Tobacco Use Monitoring Survey, 2009
Other Associations in Youth
•
•
•
Sexual and physical abuse/trauma
Other psychiatric disorders
• Eating disorders
• Depressive disorders
• Suicide attempts
• ADHD
Impoverished and dysfunctional households
Von Figueroa-Moseley et al., 2004
17 1.2. De
Nichols & Harlow, 2004
3. Menutt et al., 2002
4. Dube et al., 2003
5. Potter et al., 2004
6. Cornelius et al., 2001
Tobacco and Mental Illness
•
18
Mental illnesses associated with higher rates:
→ Schizophrenia
→ Major mood disorders
• Depression
• Mania / Bipolar illness
→ Alcohol use
→ Other substance-related disorders
→ Anxiety disorders
→ Personality disorders
1. Hughes et al., 1986
2. Grant et al., 2004
3. Breslau et al., 1991,1994
4. Lasser et al., 2000
Smoking and Schizophrenia
•
•
•
•
Prevalence rates of 72.5% (up to 90%)
More likely to smoke and less likely to quit
Biological variables
Quitting smoking may impact on symptoms of
schizophrenia:
→
→
→
19
Positive symptoms
Negative symptoms
Cognitive symptoms
Baker et al., (2010). Smoking and Schizophrenia: Treatment
approaches within primary care. Primary Psychiatry, 17(1):4954
Psychotropic Drug Interactions
Impacted:
• Clozapine
• Olanzapine
• Haloperidol
• Chlorpromazine
• Caffeine
20
DeLeon, J. (2004). Psychiatric Serv. 55: 491-493.
Not Impacted:
• Risperidone
• Ziprasidone
• Aripiprazole
• Quetiapine
• Bupropion
Psychotropic Drug Interaction
Example: Clozapine
•
•
•
Smoking cessation leads to increased clozapine
plasma levels of up to 50%, which could lead to
adverse events and toxicity (1)
– Increase could persist to up to 4 weeks
Plasma levels should be monitored frequently (2)
Dose may require lowering of 30-40% of original dose
(3)
•
Warning signs that medication dose needs adjusting (3)
– Worsening psychiatric symptoms
– Excessive fatigue or sleepiness
– Extrapyrimidal effects (i.e. tremor, slurred speech,
dystonia)
– Seizures
21
1.
Cormac et al. (2010)
2.
De Leon (2004)
3.
Lowe & Ackman (2010)
Treatment Implications
•
•
•
•
22
1.
2.
3.
4.
NRT
Bupropion
Atypical antipsychotics
Varenicline
Addington, et al., 1998
Chou et al., 2004
George at al, 2000
Evins et al., 2005
Prevalence of Smoking: Patients
with Depression
Depressed patients
56%
44%
Current smokers
23
1. Farrell et al (2003) Int Rev Psychiatry 15(1-2): 43-49;
2. Mackay et al (2006) The Tobacco Atlas 2nd ed
General population
26%
74%
Nonsmokers
Mood Disorders
•
24
1. Thorsteinsson et al., 2001
2. Hayford et al., 1999
3. Chengappa et al., 2001
Treatment
implications:
– NRT
– Anti-depressants
– Varenicline
– Bupropion
Smoking and Depression
Tobacco smoke exposure is associated with a marked reduction in brain
MAO A, which suggests that MAO A inhibition needs to be considered as a
potential contributing variable in the high rate of smoking in depression.
25
Fowler J., et al (1996) Proc Natl Acad Sci USA 93: 14065-14069
Monoamine Oxidase (MAO) Enzyme Inhibition in Smokers
This study showed that smokers have significantly reduced MAO B in peripheral organs,
particularly in the heart, lungs, and kidneys, when compared with non-smokers.
26 Fowler et al (2003) Proc Natl Acad Sci USA 100(20): 11600-11605
Smoking & Suicide Risk
P<.001
Relative riska
5
4.3
4
2.5
3
2
1.4
1.0
1
0
Never smokers
Exsmokers
1-14 (n=1333)
15 (n=2241)
Cigarettes/day: current smokers
27 Miller et al (2000) Am J Public Health 90(5): 768-773
Safety Considerations
•
History of Depression:
→
→
→
→
→
28
75% reported depressed mood < 1/52
Need aggressive monitoring and treatment
Vigilance for up to 6 months after quitting
Beck Depression Inventory, consultation with
psychiatrist
Depression is a predictor of relapse
Anxiety
•
Rates of smoking 2x greater then general
population
→
→
→
•
Nicotine is anxiogenic
→
29
Range 19.2 – 56%
Panic Disorder 40%
PTSD 63%
Lower anxiety within 2 weeks of quitting
1. Amering et al., 1999
2. Valenca et al., 2001
3. Herzbert et al., 2001
4. Hughes et. al, 1996
When is the “best” time for a person
with substance use problems to quit
smoking?
a. Before they enter addiction
treatment
b. Concurrently with their other
treatment
c. After they have been treated
30
Concurrent Treatment of Tobacco and
Other Substances
•
•
25% of clients in addiction treatment want to quit
all substances, many are willing to explore the
issue1
Relapse rates are lower if all substances are
addressed concurrently
– In a study of a substance use treatment program where
smoking was not addressed about 12% of the clients
either started to smoke or relapsed to smoking2
•
Need to address therapists’ misconceptions of
concurrent substance use treatment
– Concurrent tobacco dependence treatment does not
jeopardize alcohol and non-nicotine drug outcomes3
31
Schroeder & Morris, 2010
Kohn et al., 2003
Kalman et al., 2010
Concurrent Treatment: A Standardof-Care and a Duty-of-Practice
“A court could have sufficient basis to find
that the failure to adequately treat the main
cause of preventable disease and death
qualifies as a violation of the legal duty that
healthcare practitioners owe to patients
habituated to tobacco use and
dependence…”
(Torrijos & Glantz, 2006)
32
Alcohol and Tobacco
•
•
•
•
33
Strong correlation
Dose-dependent
Mortality rates increased
Possible gateway hypothesis?
Colby, 1994
Selby & Els, 2003
Incarcerated Individuals
•
•
•
•
34
Extremely high smoking prevalence of up to 91%
reported (2) and nearly ½ have other substance abuse
and mental health issues (3)
Limited treatment or programs available
– 1 RCT to date; outcome indicates a combination of
CBT + pharmacotherapy is an effective method for
incarcerated individuals (quit rate of 14% at 6-month
follow-up) (1)
Forced abstinence through bans leads to short-term
cessation only
– 75-100% smoking relapse rate of incarcerated
individuals upon release (3)
Smoking bans will contribute to a healthier environment,
better air quality; but should be coupled with cessation
interventions for sustained quit
1. Cropsley et al. (2008)
2. Donahue (2009)
3. Diamond et al. (2009)
People Who are homeless or
underhoused
•
•
•
•
•
35
1.
2.
3.
4.
Difficult research population
75-85 % tobacco prevalence
Master Settlement Agreement revealed
industry marketing
No peer-reviewed smoking cessation
programs
Interest likely exists in quitting
Connor et al., 2002
Folsom & Jeste 2002
Martens, 2001
Arnsten et al., 2004
Gambling Disorders
•
•
•
•
36
Strong positive association
43 – 66% tobacco prevalence
Limited empirical evidence
Systemic approaches, e.g. bans, have
little impact on monetary profits
1. Potenza et al., 2004
2. Petry & Oncken, 2002
3. Glantz & Wilson-Loots, 2003
Are you aware of the differences between
non-traditional and traditional tobacco use
in First Nations?
a.
b.
c.
37
Yes, I am sensitive to this in my
practice.
Yes but I don’t know how to
approach it with my Aboriginal
clients.
No, this is something I need more
information about.
Indigenous Populations
•
•
•
38
What is traditional use of tobacco?
Smoking rates higher
Lower age groups overrepresented
2004 Baseline Study Among First Nations
On-reserve and Inuit in the North, Environics Research Group
Smoking Among First Nations (living on-reserve)
39
Pinto A., Manson HE. (March 10, 2011). Tobacco related disparities
and equity. Presented at the Smoke-Free Ontario Knowledge
Exchange Forum, Toronto, Ontario
Smoking Among First Nations (living on-reserve)
40
Source: 2002/03 First Nations Regional Longitudinal Health Survey, as
report in RHS Quick Facts, available from:
http://www.fnigc.ca/sites/default/files/ENpdf/RHS_2002/rhs2002-03quickfacts.pdf
Factors to Consider
•
•
•
•
•
•
41
Diversity among Indigenous Populations
Access to healthcare resources
Traditional approaches to healing/recovery
Geographical location
Intergenerational trauma
Economic incentives from tobacco
sales/production in some communities
LGBTTTIQ* Population
•
•
•
•
•
•
42
1.
2.
3.
4.
5.
Limited studies & almost no Canadian data
Demographics vary & methodological flaws
Reasons for high smoking rates?
Treatment on small scale with limited
evidence
L = Lesbian; G = Gay; B = Bisexual; T= Transsexual; T = Transgendered; T = Two-Spirited;
I = Intersex; Q = Queer/Questioning
Greenwood et al., 2005
Stevens et al., 2004
Ryan et al., 2001
Tang et al., 2004
Mays & Cochran, 2001
Statistics in LGBTTTIQ Community
•
•
43
Some US studies estimate 48% of
LGBTTTIQ population smoke
Association between smoking and
bacterial pneumonia, hairy leukoplakia,
oral candidiasis and AIDS-related
dementia
Presentation by Janice Forsythe. Cypress Consulting, Ottawa (Source:
Healthy People 2010: Lesbian, Gay, Bisexual and Transgender Health.
Chapter on Tobacco Use.)
Women and Pregnancy
Why do women smoke?
•
•
•
•
•
•
Controlling weight / fear of weight gain
Addiction
Concurrent mental health problems
Coping with emotions, stress
“Fitting in”
Fashion, style and marketing
Risks decrease with quitting:
•
•
•
•
•
44
Vaginal bleeding, premature delivery, abruptio
placenta and placenta previa
Spontaneous abortion
Perinatal mortality
Better chance of having a healthier birth weight
Easier time with breastfeeding
Evidence-Based Interventions
•
•
•
45
Maximum quit rate about 20% despite best
intervention
Self-help materials tend to have good quit rates
Telephone quit lines are a cost-effective way to reach
smokers with some efficacy
• Counselling doubled abstinence rates
• Seven quit-line counselling sessions
• Brief treatment often no different than intensive
counselling
• Consider NRT if behavioural interventions do
not work
1. Zhu, 2002
2. www.Pregnets.org
3. Ershoff, 1999
Key Message
•
46
Focus on the woman’s health
Focus on Special Populations:
Implications for Tobacco Control
•
•
•
•
•
47
High prevalence & high risk
Smoking impacts disproportionately
Rates overrepresented in subgroups
Mentally ill youth at greater risk of uptake
Often not addressed by mainstream tobacco
control approaches
Contingency Management
•
•
•
•
48
Incentive based programming
Despite demonstrated efficacy in addictions limited
use in smoking cessation
Barriers include people’s attitude towards
incentives in treatment.
Ledgerwood, DM. (2008) Contingency
management for smoking cessation: where do we
go from here. Current Drug Abuse Reviews 1(3):
340-9
Suggestions for Tobacco Control
•
•
•
•
49
Identify high-risk youth
Identify hard-to-reach populations
Offer counselling/medications in
criminal justice settings
Parity of coverage
Conclusions
•
•
•
50
Evidence emerging
Supporting cessation is crucial for health
promotion
Needed:
– More comprehensive and tailored supports
– Further research
– Advocacy
Case Discussion
•
•
•
•
•
•
51
Kevin is a 45-year-old male who is living with schizophrenia
who reports regular smoking since age 14.
He is on clozapine, which he takes regularly as prescribed,
and was referred to the tobacco clinic by his community
support worker.
His support worker noticed that even though Kevin smokes
contraband cigarettes, the financial impact of his smoking
affects his overall quality of life and ability to “make ends
meet” between receiving government disability cheques.
Kevin states that he smokes approximately 76 cigarettes
per day, and says that he has been wanting to quit for a
long time.
His CO levels are 25 ppm. In his assessment, Kevin states,
“I heard you people can make quitting easy – that’s what I
need.
This is it! I am walking out of here a non-smoker.”
Discussion Questions
1.
2.
3.
4.
52
In addition to the financial impact and # of
cigarettes per day, what other areas would you
want to assess (and address) with respect to
Kevin’s tobacco use?
What do you think of Kevin’s decision to quit
immediately? How would you respond?
If you were recommending a nicotine patch, what
level would you recommend he start with?
What psychosocial intervention(s) might be helpful
in this case?
Break Time: 15 Minutes
53
Questions ?
54
Lunch!
30 Minutes
Tobacco Industry
Denormalization
Michael Perley: Director,
Ontario Campaign for
Action on Tobacco
Based on research and
presentations from the
Non-Smokers’ Rights
Association
What is Tobacco Industry
Denormalization (TID)?
•
•
•
Telling the public the truth about the tobacco
industry’s role in the perpetuation of the tobacco
epidemic in appropriate language
Show the public why the tobacco industry falls
outside the boundaries of normal business
behaviour
Reverse the industry’s decades-long effort to
normalize itself
57
Slide from Michael Perley, Ontario Campaign for Action on Tobacco
What Tobacco Industry
Denormalization Is Not
•
Messages or programs that do not refer
to the tobacco industry and its role in the
epidemic, such as those referring to
“smoking” or “smokers” as their main
subjects
58
Slide from Michael Perley, Ontario Campaign for Action on Tobacco
From this list, select one statement with
which you agree the most strongly.
a.
b.
c.
d.
e.
59
Cigarettes are too dangerous to be sold
at all;
The tobacco industry rarely/never tells
the truth about health effects of
smoking;
The tobacco industry is
mostly/completely responsible for health
problems smokers have because of their
smoking;
The Ontario government should sue
tobacco companies for health care costs
caused by tobacco products;
The tobacco industry should be fined by
government for money earned from
tobacco sales to minors.
Tobacco Industry Behaviour
1950s-60s
• First linkage of tobacco-lung cancer in medical
literature; industry PR firm suggests counterattack against scientists to reduce public worry
• The TIRC plan: spend massively to block
scientists and public health officials from warning
people of potential health hazards
• Industry researchers find numerous carcinogens
in tobacco smoke: research hidden
60
Slide from Michael Perley, Ontario Campaign for Action on Tobacco
61
Tobacco Industry Behaviour (2)
•
In 1962, the Chairman of British American Tobacco
asked:
“If we make safer brands, how to justify continuing
the sale of other brands? It would be admitting that
some of (our) products already on the market might
be harmful.”
(A McCormick, British American Tobacco, 1962)
1970s
•
“Safer” cigarettes designed and tested, but
companies could no longer afford to offer safer
cigarettes to smokers
62
Slide from Michael Perley, Ontario Campaign for Action on Tobacco
63
Tobacco Industry Behaviour (3)
The 1977 Bath Summit (BAT, PM, ITL, RBH,
RJR): agreed to deny known health effects
of tobacco and conceal known toxicity of tar,
nicotine and other chemicals in tobacco
1980s
• Company scientific labs shut down, medical
findings hidden or destroyed
•
64
Slide from Michael Perley, Ontario Campaign for Action on Tobacco
Industry Tactics
Lies and Deception
Junk Science
Youth
Programs
Corporate
“Philanthropy”
Advocacy
How the
industry
normalizes
tobacco
Third
Parties
Hollywood
65
Slide from Michael Perley, Ontario Campaign for Action on Tobacco
Advertising
Sponsorship
What the Industry Really Thinks
“In order to make further inroads into the
younger segment, we must continue to project
an image that is consistent with the needs and
values of today’s younger smokers.”
(RJR, 1989)
“Although the key 15-19 age group is a must
for RBH there are other bigger volume groups
that we cannot ignore.”
(RBH, 1997)
66
Slide from Michael Perley, Ontario Campaign for Action on Tobacco
What the Industry Really Does
“The 1988 tracking study is the second
of a planned series of research studies
into the lifestyles and value systems of
young men and women in the 13-24 age
range.”
(ITL, 1988)
67
Slide from Michael Perley, Ontario Campaign for Action on Tobacco
Operation ID:
The Tobacco Industry’s
Youth-Friendly Face
68
Concerned About
Children Smoking?
We Are, Too!
69
Three on
Three Hockey
70
Lanny McDonald
71
Guy Carbonneau
72
In 2002, the Ontario Medical Association drew
the following conclusions about Operation ID:
•
•
•
73
“Tobacco industry documents make clear that
their youth access programs have little or
nothing to do with reducing youth smoking”.
“The failure of these programs is inevitable
because they are voluntary”.
“Youth access and educational programs
target the wrong outcome, access, rather than
consumption”.
“More Smoke and Mirrors: Tobacco Industry-Sponsored Youth
Prevention Programs in the Context of Comprehensive Tobacco
Control Programs in Canada”, February 2002
Key Industry Tactics/Messages
A risky – but legal – product
• “We don’t market to children”
• Light and mild
• Questionable research (attacks on the risks of
second-hand smoke)
• Cigarette smuggling uncontrollable
• Rights and freedoms: the “nanny state”
• Economic fallout
• Front groups (mychoice.ca [now defunded by ITL],
FAAC, hospitality)
74
Slide from Michael Perley, Ontario Campaign for Action on Tobacco
Industry Tactics:
Advertising and Promotion
•
•
•
•
•
Power walls (banned in most provinces)
Point-of-sale signage and displays (as above)
Branding
Movies
Grey areas (bar promotions)
75
Slide from Michael Perley, Ontario Campaign for Action on Tobacco
Industry Sponsored Tobacco
Promotions
76
http://www.tobaccofreekids.org/ adgallery/display.php3?ID=204
77
Benson and Hedges Cigarette Girls for a 2003 promotion aimed at
Young Adults
The Industry’s Behaviour Today
78
The Industry’s Behaviour Today
79
The Industry’s Behaviour Today
Post Bill C-32 and Ontario Bill 124, cigarillos have simply
become small cigars without filters, but with the same
attractive flavours such as cherry, strawberry and peach.
80
Flavoured Tobacco Products
81
82
Tobacco Industry Denormalization
Strategies
Objective: Expose the Industry
• Combat myths about tobacco products
• Draw attention to nature, extent, impact of
tobacco industry advertising/promotional
activities
• Draw attention to role of other organizations
in supporting promotion and sale of tobacco
83
Slide from Michael Perley, Ontario Campaign for Action on Tobacco
Tobacco Industry Denormalization
Strategies (2)
•
Paid media (CA, Mass., other US states)
•
Earned media (NSRA exposure of St.
Michael’s University acceptance of ITL
corporate ethics funding; CCS/NSRA
protest chief tobacco lobbyist’s presence on
WCH board; U of Sask. SU rejects
$250,000 grant from ITL)
•
Research/lobbying/advocacy
84
Slide from Michael Perley, Ontario Campaign for Action on Tobacco
Unsweetened Truth
85
Do You Have What it Takes…?
86
Smokenders
87
Smoking Dog
88
Demon Awards
89
Contraband
Contraband
What does this word mean to you?
With a partner, discuss this for a few
minutes.
91
Are some cigarettes more harmful
than others?
A. No- all have the same level of
danger to health, no matter
where the cigarettes are
manufactured
B. Yes- unregulated cigarettes are
more harmful
C. Maybe- I need some more
information to make a decision
92
The 1990s Smuggling Crisis
•
Tobacco industry-driven: tax-free main-brand
industry products exported to bonded warehouses
in New York State, smuggled back into
Ontario/Quebec
•
Result: Federal and several provincial
governments cut tobacco taxes by 50% in 1994
•
Impact: Up to 40,000 excess deaths as a result of
increased youth smoking (Health Canada draft)
93
Slide from Michael Perley, Ontario Campaign for Action on Tobacco
Smuggling/Contraband Today
•
The product: 200-cigarette
“baggies” manufactured on 4-5
U.S./Ontario/Quebec reserves
(contrast: 190+ reserves in
Ontario alone)
•
Involvement of non-FN
organized crime elements:
contraband tobacco trade
funds smuggling of
drugs/guns/people
94
Slide from Michael Perley, Ontario Campaign for Action on Tobacco
Smuggling/Contraband Today (2)
•
A problem for all communities:
$8-10/baggie cigarettes vs. $5070+ discount/main brands help
lead to 1) FN community
smoking rate of 59%; 2)
flattening/reversal of non-FN
prevalence declines
•
Sources: on-reserve smoke
shacks (some southern Ontario/
Quebec reserves), off-reserve
non-FN supply chains
95
Slide from Michael Perley, Ontario Campaign for Action on Tobacco
96
97
98
Solutions
•
Nation-to-nation negotiations/trade and
other economic agreements
•
Off-reserve enforcement esp. re:
organized crime
99
Slide from Michael Perley, Ontario Campaign for Action on Tobacco
Ontario’s Bill 186
•
•
•
•
•
100
Tobacco leaf management system
Fine cut tobacco marking system
New fine structure
Seizure “in plain view”
Arrangements and agreements with First
Nations
Questions?
101
Break Time: 15 Minutes
102
Harm
Reduction
What is your perspective on harm
reduction and tobacco use?
a. There is no such thing – all tobacco use
is harmful
b. I can see that might be necessary with
some populations
c. I believe in using a harm reduction
approach
d. I’m not sure - I need more information
104
Discussion
What is one thing you want to
take away about harm
reduction?
105
“ Don’t give up the ship in a storm because you cannot hold
back the winds. You must not deliver strange and out of
the way speeches to people with whom they will carry no
weight because they are firmly persuaded the other way.
Instead, by an indirect approach, you must strive and
struggle as best you can to handle everything tactfully –
and thus what you cannot turn to good, you must at least
make as little bad as you can.”
106 St. Thomas More 1478-1535, Utopia, CWM, v. 4, pp. 99, 101-(More,
Thomas
LoganSt.
et al.
1995)
More 1478-1535, Utopia, CWM, v. 4, pp. 99, 101-(More, Logan et al. 1995)
Do you drive a car with
anti-lock brakes?
a. Yes
b. No
c. Do bikes count?
107
Which type of vehicle allows you
to stop faster?
a. Cars with anti-lock brakes
b. Cars without anti-lock
brakes
c. No difference
108
Tobacco Harm Reduction
TOTAL HARM
Harmfulness
Danger
Intensity
109
MacCoun and Reuter 2001
Prevalence
Issue: The Precautionary Principle
– Can science of nicotine help?
•
•
The precautionary principle:
– "When an activity raises threats of harm to human
health or the environment, precautionary measures
should be taken even if some cause and effect
relationships are not fully established scientifically. In
this context the proponent of an activity, rather
than the public, should bear the burden of proof."
A key issue in advocating a tobacco control harm
reduction strategy involving the use of less harmful forms
of nicotine delivery, is the evidence of safety of nicotine
per se.
110
Wingspread statement
Most Harmful –
least regulated
Some Harm – some regulation
111
Least Harmful – most regulated
A Controversial Topic?
•
•
•
112
Tobacco control has always taken a harm
reduction perspective
– Smoke free policies, taxation, etc.
There is support for harm reduction – CAMH,
OMA
What do we mean by harm reduction?
http://www.maricopa.gov/Public_Health/Community/Tobacco/
113
General View on Harm Reduction
•
•
•
•
•
114
Aims to reduce the adverse health, social,
and economic consequences of drug use
without requiring abstinence
Abstinence is healthiest choice
Focuses on the most immediate and
achievable changes
Public health alternative to the
moral/criminal and disease models of drug
use
Non-judgmental, non-coercive
General Principles of Harm
Reduction
•
•
•
•
115
End users should have a voice in the creation
of programs and policies designed to serve
them (client-centered care)
Values patient autonomy and provider patience
Culturally sensitive
Although abstinence from tobacco is
recommended, many smokers are unable or
not ready to quit
Benefits of Harm Reduction
Approach (1)
Daily use
Reduction
Continuum
•
•
•
116
Engages
Increases confidence
Changes behavioural patterns
Abstinence
•
•
•
•
117
“Quit or die” is
irresponsible, unethical
and unrealistic
Millions are highly
addicted and have low
cessation rates
Appears deeply rooted in some communities (I.e.:
those with mental health issues, aboriginal)
Creates a market incentive for ever-better products
to replace cigarettes
Cautions against Harm
Reduction
•
•
•
•
•
118
Distraction from quitting
– Need more resources devoted to quitting
Premature admission of defeat
Extra harm to people that would have otherwise quit
completely
Potential for young people to start with products
they believe it to be safe
Ex-smokers may use products as an option causing
relapse
Benefits of intermittent quitting on reducing death
119
From Lung Health Study – 14.5 year follow-up
Slide from Paul McDonald
Effective Harm Reduction
Strategies
•
•
•
•
•
•
120
Product regulation – warnings on packages, making
cigarettes taste bad, anti-counterfeiting
Changing nature of products containing nicotine
– Low nitrosamine cigarettes only cut out 1 carcinogen
Taxation - increasing the amount of taxes on cigarettes
decreases consumption especially with 18-24 year olds
Limiting access / visibility – retail displays being removed.
“Out of sight out of mind”
NRT, bupropion and other approved cessation
medications
Eliminating provincial sales tax in Ontario on nicotine
replacement products``
NRT and Reduction
•
•
•
•
•
•
Cleaner, safer delivery system of nicotine
Separates addictive behaviour from harm
Prevents use of tobacco products to help
with withdrawal
Increases familiarity with cessation
products
Combined with other treatment
(behavioral, emotional triggers)
New literature = start NRT two weeks
before quit date
121 http://www.ash.org.uk/html/cessation/Smoking%20reduction/NARS0
51014.pdf
Evidence for Cardiovascular Harm:
Nicotine in Animal Studies
122
Evidence for Cardiovascular
Harm – Humans
•
•
•
•
•
•
123
Blood pressure: older studies, higher resting
BP, newer studies, no effect.
Heart rate: mild increase but not significant
Waist-hip: nil/variable
BMI: variable
Max workload capacity: no difference
Insulin resistance higher risk both in long term
NRT users. Variable in smokeless users.
Asplund 2003; Progress in Cardiovascular Diseases
Conclusion
•
•
•
•
124
Nicotine may have increased cardiovascular
effects that are associated with increased
morbidity and mortality mainly in smokers.
However, compared to smoked tobacco, other
forms have less risk and at times are similar to
that of non-smokers.
In Sweden, many males switch to smokeless as a
means to quit smoking.
NRT appears to be safe. However long-term use
only examined in the Lung Health Study 1996.
Evidence of Harm in Pregnancy
•
•
•
•
•
•
125
Nicotine is a neuroteratogen
However, CO and Thiocyanates also
play a role
Smoking is associated with cleft lip, low
birth weight, SIDS
Downstream psychiatric symptoms in
children
However, most pregnant women
continue to smoke while pregnant even
with the best available intervention.
Fetocentric versus woman-centred
approach
NRT in pregnancy
•
•
•
•
126
Try behavioural interventions first
When cannot quit, try intermittent forms of
NRT starting with lowest dose
If using patch, remove at bedtime
Continue behavioural support
Benowitz et al, AJM: 2008
4 Cell Stage of Human Embryo
A. Both
parents
smoke
C. Mother
smokes
127
Zenzes MT et al, Mol Human Reprod (1999) 5: 125-131.
B. Father
smokes
D. Nonsmoking
parents
Cigarettes and Reproduction
•
•
•
128
Women who smoke undergo menopause 1 to 4
years earlier than non-smokers.
Zenzes et al have shown that smoking causes
benzo(a)pyrene diol epoxide DNA (BPDE-DNA)
adduct formation in human sperm
Similar proportions of BPDE-DNA adducts in
embryos where both parents smoke, compared to
where only the father smoked, suggested that
contribution of DNA adducts is mainly from sperm
Implications
•
129
Understanding the role of nicotine in the
harm caused by smoking is important if
smokers are to be encouraged to use less
harmful nicotine delivery devices and will
help to identify where a cautious approach
might be necessary as well as gaps for
further research.
When does a person’s risk of developing
lung cancer become high? ( > 10 times
the risk of a non-smoker)
a. Up to 10 cigarettes per day
b. Between 10-19 cigarettes per day
c. 20 cigarettes per day
d. Between 21-31 cigarettes per day
e. More than 31 cigarettes per day
130
Does Reduced Smoking Result in Less
Harm? A Cautious Example
Table 1: Risk of developing lung cancer as a function of the number of
cigarettes /day
131
# Cigarettes day (c.p.d)
Related Risk
0 (non smoker)
1.0
1-10
5.5
11-19
11.2
20
14.2
21-31
20.4
>31
22.0
The more you smoke the more at risk you are of developing health
issues. The opposite in not necessarily true as smokers can titrate
the amount they get from each cigarette therefore getting more
from less
What about……….
One can contains 4 x the nicotine in a
pack of cigarettes
Tobacco or tobacco blends that are chewed or
sucked on. A person who uses eight to 10 dips or
chews a day receives the same amount of nicotine
as a heavy smoker who smokes 30 to 40
cigarettes a day
132
http://www.tobaccofacts.org/tob_truth/spit.html
Snuff, Chews and Plugs……
Snuff – Fermented,
ground-up moist
tobacco usually placed
between the bottom lip
and gum. This is also
referred to as "dipping“
(Swedish form is Snus –
lower risk).
133
Chew – shredded
tobacco leaves
placed between the
cheek and gum.
This is also referred
to as "a wad".
Plug – shredded
tobacco leaves
which are pressed
into a hard block
and placed between
the cheek and gum
134
Ingredients in Smokeless
Tobacco
•
•
•
•
•
•
135
Nicotine: poisonous and highly addictive drug
Carcinogens: many cancer-producing chemicals have been
identified in smokeless (spit) tobacco.
Sweeteners: tobacco has an unpleasant taste, some brands of
smokeless tobacco are heavily sweetened with sugars, which
promote tooth decay.
Abrasives: scratch the soft tissues in the mouth, allowing the
nicotine and other chemicals to get directly into the blood system.
Salt: Flavouring salts found to contribute to abnormal blood pressure
and kidney disease.
Other Chemicals: Hundreds of other chemicals can be found in
tobacco which contribute to many health problems.
Health Risks of Smokeless
Tobacco (1)
•
•
•
136
Mouth Cancer – cancer of the cheeks,
gums, lips and tongue. Smokeless (spit)
tobacco users have a 50% higher chance of
getting oral cancer than non-users.
Throat Cancer – cancer of the voice box and
cancer of the esophagus.
Heart disease – heart attacks,
strokes and high blood pressure.
http://www.health.gov.sk.ca/rr_smokeless_tobacco.html
Health Risks of Smokeless
Tobacco (2)
•
•
•
•
137
Dental diseases – stained teeth, tooth decay,
receding gums, gum disease, bad breath and black
hairy tongue.
Stomach problems – ulcers, stomach upset,
increased bowel activity and stomach cancer.
Loss of taste and smell – causes loss of appetite
which results in poor nutrition and poor health.
Physical changes – fatigue, muscle weakness,
dizziness and decreased physical performance,
dermatologic changes
http://www.health.gov.sk.ca/rr_smokeless_tobacco.html
Cutaneous Manifestations of
Smoking
•
•
•
•
138
aPlethoric
denotes a red florid complexion.
Freiman et al. J Cutan Med Surg. 2004;8(6):415-423.
Prominent periorbital
lines
Gauntness
Graying of the skin
Plethorica complexion
Signs of Smoking
Clinical Signs
Harlequin nail
Synonyms
Quitter’s nail
Smoker’s comedones
Smoker’s face
Large comedones with furrows and
nodules
a) Lines or wrinkles
b) Gauntness
c) Graying of the skin
d) Plethoric complexion
Smoker’s melanosis
Pigmentation of the gingiva
Smoker’s moustache
Moustache discoloration
Smoker’s nail
Nicotine sign
Smoker’s palate
Nicotine stomatitis, leukokeratosis Coloration of the palatal mucosa
nicotina palati
Leukokeratosis nicotina glossi
Pink-coloured depressions
Smoker’s tongue
Snuff dipper’s lesion Smokeless tobacco keratosis,
tobacco pouch keratosis
139
Description
Demarcation line in the nail
Freiman et al. J Cutan Med Surg. 2004;8(6):415-423.
Nail discoloration
White lesion in the oral cavity where
smokeless tobacco is held
Smoking-Attributable Periodontitis
•
•
•
140
Smoking is a major risk
factor for periodontitis
Current smokers are
approximately 4 times
as likely as persons
who have never
smoked to have
periodontitis
Periodontal disease is
one of the main causes
of tooth loss worldwide
Tomar et al. J Periodontol. 2000;71(5):743-751; http://www.cdaadc.ca/en/oral_ health/complications/tobacco/ smokeless.asp. Accessed
October 19, 2007.
Gum Recession
141
Leukoplakia
142
Brown Hairy
Tongue
J Contemp Dent Pract. 2005;6:158-166; Lewin et al. Cancer.
143 Davis.
1998;82:1367-1375.
Nicotine
Stomatitis
Oral Cancer
144
Smokeless Tobacco Prevention
Websites
145
•
http://mylastdip.com/ - Web-based
intervention that is designed to help young
chewing tobacco users quit.
•
http://www.chewfree.com/ - Website
created to help people quit their use of
chewing tobacco or snuff.
ST NRT Dosing Algorithm Spit Tobacco Algorithm
ST / Week
Patch / Gum / Lozenge Dosage
2 tins or less /
week
Patch: 14 mg. x 4 weeks
7 mg. x 4 weeks
Gum / Lozenge*: 8 – 12 4-mg pieces per day x 8 weeks
(not to exceed 24/20 pieces per day)
>2 but <5 tins /
week
Patch: 21 mg plus gum or lozenge*
21 mg x 4 weeks
14 mg x 2 weeks
7 mg x 2 weeks
As needed gum / lozenge*: 4 – 8 pieces per day /4 mg
OR:
Gum / Lozenge*: 12 – 16 4-mg pieces per day x 8 weeks (not to
exceed 24/20 pieces per day)
5 or more
tins/week
Patch: 21 mg plus 4-mg gum or lozenge*: 1 per waking hour
OR:
Gum/Lozenge*: 16 – 20 / 4-mg gum or lozenge per day for 8
weeks (not to exceed 24/20 pieces per day)
* for Lozenge enter First Tobacco Use to indicate within 30 minutes of waking
© Dr. Herb Severson, Oregon Research Institute (ORI), 2010
Comments
If patch adjust dosage to
be 14 mg as starting
dose. (14 mg x4 weeks; 7
mg x 4 weeks)
If prt is concurrently using
any other form of tobacco
w/ ST, increase starting
dosage to 21 mg patch
Snus
•
•
•
aThe
147
Moist smokeless
tobacco, snuff
Although used
worldwide, the highest
consumption of snus is
in Sweden
Associated with an
increased risk of
pancreatic cancer
(RR 2.0; 95% CI, 1.23.3a)
probability of an event (developing a disease) occurring in exposed
people compared with the probability of the event in nonexposed people.
Luo et al. Lancet. 2007. Epub ahead of print;
http://www.arnestadphotography.com/stock_photos/albums/concept/snuff_
tobacco_black.jpg. Accessed October 19, 2007.
Snus
Different from other chew
tobacco – it is sterilized, decreasing the number of
nitrosamines (cancer-causing agents)
• Reduced risk of lung cancer
• No emphysema
• 2x risk of pancreatic cancer
(down from 3x risk with smoking)
•
148
Snus
•
•
•
149
International researchers followed 279,897
male Swedish construction workers from 1978
to 1992. About 26 percent were snus users, 37
percent were smokers and the rest never used
tobacco.
For smokers, the incidence rate of pancreatic
cancer was 13 cases per 100,000 versus 8.8
cases per 100,000 for snus users.
Among those who did not use tobacco, the
rate was 3.9 cases per 100,000.
Hookah: Waterpipe Tobacco
Smoking
•
•
•
•
•
150
Shisha, a mixture of tobacco, molasses, and
fruit flavors used
in the hookah
Water in the hookah does not diminish
tobacco toxicity
A 1-hour session of hookah smoking
exposes the user to 100- 200 times the
volume of smoke inhaled from a single
cigarette
Smoke produced contains high levels of
carbon monoxide, heavy metals, and other
carcinogens
Delivers significant levels of nicotine
World Health Organization.
http://www.who.int/tobacco/global_interaction/tobreg/Waterpipe%20re
commendation_Final.pdf; Sajid et al. J Pak Med Assoc.
1993;43(9):179-182.
151
152
Smokeless Tobacco as Harm
Reduction? (1)
•
•
•
153
As dependence-forming as cigarettes
Users develop cravings and nicotine
withdrawal when abstaining
Does not produce second-handsmoke BUT people who dip or chew
spread their germs when they spit.
This increases the risk of passing an
infection to others.
Smokeless Tobacco as Harm
Reduction? (2)
•
•
•
•
154
90% of smokeless tobacco users are regular
users before age 18
Almost all users are male
High co-use of cigarettes (est. 10-20%)
38% of users develop oral lesions within 3
years
Smokeless Tobacco Cessation
•
•
•
155
Nicotine lozenge appears to be the
most preferred cessation aid
Presence of lesions is an opportunity to
motivate behaviour change
2 week rule: If lesions do not heal within 2
weeks, recommend a biopsy
New Smokeless Cessation AidMint Snuff
•Non tobacco product, edible
and made with real mint
•Safe to swallow/eat
•Available in 4 flavours
•Mint Snuff Pouches are
miniature teabags filled with
Mint and Mint Oil Crystals.
•1-800-EAT-MINT
156
www.mintsnuff.com
Bottom Line on Harm Reduction
Using fewer tobacco products may have little
to no effect on reducing morbidity and
mortality
BUT
Reducing consumption may increase
likelihood of future cessation
157
What is your perspective on harm
reduction and tobacco use?
a. There is no such thing – all tobacco use
is harmful
b. I can see it that might be necessary with
some populations
c. I believe in using a harm reduction
approach
d. I’m not sure - I need more information
158
TEACH Exam
Evaluation
and Wrap Up
TEACH Community of Practice &
Listserv
As a graduate of this course, you are eligible to join the
TEACH Community of Practice Listserv! Our TEACH COP
Listserv is configured so that you need to self-register,
which quick and easy to do.
To “subscribe” to the Listserv, please send an email to:
teach-request@info2.camh.net
and write: “subscribe teach” in the subject line of your email.
You will then receive a message confirming your
subscription to the List, as well as instructions on how to
post or unsubscribe.
161
Course Evaluation:
3 Things to Remember
1. Please complete the Evaluation Form before you
leave.
2. Log on to the TEACH Website to make sure you’ve
completed Learning Assessments # 1& #2 (you must
complete both in order to receive the CAMH Letter of
Completion and U of T Certificate).
3. Online follow-up survey in three and six months –
TEACH will send you a reminder !
162
Are you interested in becoming a
Tobacco Cessation Practice Leader?
An Opportunity to….
• Develop your skills
• Network
• Attend TEACH courses
• Achieve credit units
Possible Roles…..
- Clinical Consultation
- Conference Speaker
- In –Service Trainer
- Media Interviews
- Resource Link
Questions? Email: teach@camh.net
163
How would you rate this course?
a. Excellent
b. Very good
c. Good
d. Fair
e. Poor
164
Please remember to
leave your i-clicker
on your table,
Thanks.
165
166