Addressing Persistent
Tobacco Use in Persons
with Cardiopulmonary
Disease
Audrey Darville, PhD, APRN, CTTS
Certified Tobacco Treatment Specialist
UK HealthCare/UK College of Nursing
March 5, 2015
Impact of Smoking on the Heart
At age 50 years with >2 risk factors, lifetime risk of
CVD is:
• 50% for a woman
• 70% for a man
Age at ACS admission
• Male smokers were more than 9 years
younger than the nonsmoking men
• Female smokers were more than 13 years
younger than the nonsmoking women
Lloyd-Jones D. Circulation. 2010
Go AS. Circulation. 2013
Howe M. Am J Cardiology. 2011
INTERHEART—Risk of first MI
Population Attributable Risk (%)
36
50
33
80
20
60
18
40
10
20
0
Smoking
Yusuf S. Lancet. 2004
Hypertension
Diabetes Abdominal
obesity
Psychosocial
Lipids
Impact of Smoking on the Lungs
Even low levels of tobacco smoke
significantly effect smokingresponsive genes in the small
airway epithelium
Strulovici-Barel, et al. American Journal of Respiratory and Critical Care Medicine DATE
Smoking, COPD & Gender
Lung function reduction and COPD severity
were the same for male and female subjects,
but women were:
• younger
• started smoking at a later age
• had smoked fewer pack-years
Differences were more pronounced in the earlyonset and low exposure COPD subgroups
Sorheim, et al. Thorax. 2010
So Why Do People Use Tobacco?
The Tobacco Industry wants us to
believe tobacco use is a personal
choice
Case Study
Mr. J., 46, has severe heart disease from
multiple heart attacks and continues to
smoke 2 PPD. When asked about his
tobacco use, he replied it had nothing
to do with his heart attacks, so there
was no point in talking about it as he
just gets “ugly” when he doesn’t
smoke.
What was the origin of his beliefs?
• After his heart attacks his doctor told him he
needed to cut out eating salt and fat and lose
weight. He said “nothing about smoking” (that the
patient heard)
• Many family members smoke and their hearts
were OK
• Stress would kill him faster than smoking and his
life was pretty stressful
• “If someone tells me to do something, I’m going to
do the opposite. That’s just how I am.”
Is he ready to quit (and does it
matter)?
• Consider how complex it is to describe
the effects of tobacco on the heart
• Consider his experiences with tobacco
and quitting
Is it the Habit or the Drug?
• “Choice” is the Tobacco Industry
message…
• Do we consider tobacco use (nicotine
addiction) a chronic disease?
• Addiction is not logical: We generally
won’t convince someone that nicotine
patches are cheaper than cigarettes
• Are we dispelling “myths of smoking”
effectively?
Cessation “Myths” to be challenged
• In order to quit you really have to want to quit
• Medications are more harmful than smoking
• Some people just can’t/won’t quit
• Medicine won’t work unless you want to quit
• You don’t need to talk about it, you just need to
do it
• Don’t try to quit smoking when you’re trying to
get sober or quit drugs, it’s too stressful
• Reducing your smoking or switching to
smokeless/e-cigs are better for your health
What’s Motivation Got to Do with
It?
• What constitutes “Motivation”?
• How is it different than
“Readiness”?
• What is the clinical evidence for
the role of motivation in behavior
change?
Motivation
According to Google…
• The reason or reasons one has for
acting or behaving in a particular way.
• The general desire or willingness of
someone to do something.
Components of Motivation
Importance/Salience
“I really have to quit”
“Smoking is killing me”
Confidence/Self-efficacy
“I’m too stressed to quit right now”
“I’ve tried to quit so many times”
Readiness versus Motivation
•Readiness focuses on the
barriers
•Motivation explores the
REASONS behind the barriers
The Science in a nutshell…
• Motivational interviewing may help people
quit and is widely used
• Most effective when used by trained
professionals
• Avoids aggressiveness and confrontation
• More is better
Motivational interviewing for smoking cessation (Cochrane
Review). 2010
How it Works
A content analysis of a Randomized Control Trial found counseling:
• Supports confidence about quitting and reduces perceived difficulty
quitting
• Prompts avoidance of access to cigarettes
• Improves quitting self-efficacy
• Reduces perceived difficulty of quitting over time
• Protects against guilt and demoralization following lapses
• Supports the importance of receiving social support
• Strengthens motivation and confidence
• Eases withdrawal distress during cessation efforts
McCarthy, et. al. Addiction. 2010.
Understanding Disparities…
• “Nicotine-dependent individuals
with a comorbid psychiatric
disorder made up 7.1% of the
population yet consumed 34.2% of
all cigarettes smoked in the United
States”
• Persons with mental illness die, on
average, 25 years younger than
the general population
Grant, B.F. , et al. Archives of General Psychiatry 2004.
Putting it into Practice
Quit Rulers:
Helpful to Know…
• Age of onset of smoking
• Nicotine dependence (high if time to first cigarette is
30 minutes or less)
• Prior quit attempts/methods used
• Exposure to other smokers/secondhand smoke
Components of Effective
Counseling
Promoting Importance of Quitting:
Develop discrepancies between
current behavior and desired behavior
Promoting Confidence to quit:
Develop a plan and engage useful tools
(including medication) to assist in
changing behavior
Tailored Approaches Work:
Reducing to Quit
• A Cochrane Review (Lindson, Aveyard &
Hughes, 2010) found 10 studies that
looked at reducing cigarettes prior to
quitting compared to making no change in
CPD smoked
• Found no significant difference between
the 2 strategies in quit rates, concluding
either strategy can be recommended for
quitters (tailoring)
ROADBLOCK: Switching to Quit
(aka Harm Reduction)?
• Strategy that is causing international
controversy in tobacco control
• Involves promoting the use of alternate
products (smokeless tobacco including
snus, electronic cigarettes most
commonly)
• A significant amount of harm reduction
science receives funding from the tobacco
industry
Is Less Harmful=Not Harmful?
• Tobacco industry is aggressively marketing
smokeless and novel tobacco products, such as ecigarettes, as “less harmful” alternatives to
smoking traditional cigarettes
• Smokeless use has been associated with an
increased risk of fatal MI and Stroke Piano, et al (2010),
Yatsuya & Folsom (2010)
E-cig Concerns
• FDA regulation is pending: No current
standards exist
• Particulates, including tin, have been found in
the inhaled vapor Williams, et al., Plos One, 2013
• Acute pulmonary effects similar to tobacco
smoke effects have been seen in electronic
cigarette users Vardavas, et al. Chest 2012
• Case report of lipoid pneumonia attributed to
e-cig use McCauley, et al, Chest, 2012
E-cig Marketing Forces At Work
Now that big tobacco companies are major players in the ecig market there has been an explosion in marketing (déjà vu?):
Additional Evidence-Based
Techniques
• Expressing Empathy: “What do you like
about smoking? How does it help you?”
• Rolling with Resistance: “It’s hard to find a
good time to quit. What do you think will
help you move forward?”
• Supporting self-efficacy: “Tell me how the
medication is doing for you.”
The Full-Court Press
• With cessation treatment, more is always
better
• Counseling (in person, online, text support)
plus medication most effective at helping
people quit and STAY quit
• Quitline is FREE, EFFECTIVE and EASY via
electronic referral at:
https://www.quitnowkentucky.org/eReferral/
Arming Yourself (resources)
• www.smokefree.gov
• Treating Tobacco Use and Dependence Clinical
Practice Guideline:
http://www.ahrq.gov/path/tobacco.htm
• Association for the Treatment of Tobacco Use
and Dependence: www.attud.org
• Free CE:
http://www.cecentral.com/ManagingNicotineWi
thdrawal
Questions Now or Later…
Audrey Darville, PhD, APRN, CTTS
Certified Tobacco Treatment Specialist
University of Kentucky
College of Nursing
450F CON
Lexington, KY 40536-0232
audrey.darville@uky.edu
859-323-4222