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