Cancer, Cardiovascular and Pulmonary Pathophysiology Linked to Tobacco

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Cancer, Cardiovascular and Pulmonary
Pathophysiology Linked to Tobacco

• Carlos Roberto Jaén, MD, PhD, FAAFP
• Professor and Chairman
• Family and Community Medicine
• University of Texas Health Science Center
• at San Antonio

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Overview

• Health consequences of smoking on cancer,
  cardiovascular and pulmonary diseases
• Smoking cessation strategies that work!
• Leading edge areas of research in primary care
  clinical settings

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Health Consequences of Smoking on Cancer,
Cardiovascular and Respiratory Diseases

• The 2004 Surgeons General Report

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Cancer

• Most cells in the body continually divide and die
  off in a very controlled way.
• Some chemicals can interfere with the cell
  division process, causing a cancer to develop.
• Cancer tends to leave the original location and
  spread through the body this is called
  metastasis. When the body cannot keep up with
  the growth of cancer, the patient dies.

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Cancer

• Cancer is the second leading cause of death in
  the United States.
• In 2003 it is estimated that more than half a
  million would die from cancer, more than 1500
  people a day.
• The risk of dying from lung cancer is more than
  22 times higher among men who smoke cigarettes,
  and about 12 times higher among women who smoke
  cigarettes compared with never smokers.

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Cardiovascular Diseases

• Heart disease and stroke are the first and third
  leading causes of death in the United States and
  are caused by smoking.
• More than 61 million Americans suffer from some
  form of heart or blood vessel disease including
  high blood pressure, coronary heart disease,
  stoke and heart failure.

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Cardiovascular Diseases

• Nearly 2600 Americans die daily as a result of
  cardiovascular diseases or about one every 33
  seconds.
• Most cases of these diseases are caused by
  atherosclerosis, a hardening and narrowing of the
  arteries.
• Damage to arteries and blood clots that block
  blood flow can cause heart attacks or strokes.

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Cardiovascular Diseases

• Cigarette smoke damages the cells lining the
  blood vessels and heart.
• The damaged tissue swells, and makes it hard for
  blood vessels to get enough oxygen to cells and
  tissues.
• Cigarette smoke increases the risk of dangerous
  blood clots both by redness and swelling and by
  causing blood platelets to clump together.

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Pulmonary Diseases

• Smokers have difficulty fighting infections well,
  these infections cause lung tissue injury that
  leads to chronic obstructive pulmonary disease
  (COPD), sometimes called emphysema and other
  pulmonary diseases.
• People with COPD slowly start to die from lack of
  air.

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Pulmonary Diseases

• COPD is the fourth leading cause of death in the
  United States, accounting for about 100,000
  deaths a year.
• About 90 of all deaths from COPD are
  attributable to cigarette smoking.
• Most sudden respiratory illnesses are caused by
  viruses and bacteria. Smokers have a weaken
  immune system that has difficulty clearing these
  infections from the lungs.

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Pulmonary Diseases

• Chronic lung diseases are long lasting and affect
  the airways and the tiny sacs where oxygen is
  absorbed into the lungs.
• Injury begins when smoke causes lung tissue to
  become red and swollen. This releases unwanted
  oxygen molecules that damage the lung. It also
  causes release of enzymes that can eat delicate
  lung tissue.

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So..

• Major cancers, cardiovascular and respiratory
  diseases are caused by tobacco use.
• Is there experimental evidence that smoking
  cessation reduces mortality?
• Are there effective treatments for smoking
  cessation?

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The Lung Health Study

• Randomized clinical trial of smokers with mild
  COPD treated with intense cessation intervention
  (12 two-hour sessions over 10 weeks)
• Significant benefits of cessation at 14 ½ years
  of follow-up, even though only 22 quit in the
  intervention group vs. 5 in usual care group
• First randomized trial to confirm prior
  epidemiological observations.

Anthonisen, N. R. et. al. Ann Intern Med
2005142233-239
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All-cause 14.5-year survival
Anthonisen, N. R. et. al. Ann Intern Med
2005142233-239
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Mortality rates at 14.5 years by cause and
smoking status
Anthonisen, N. R. et. al. Ann Intern Med
2005142233-239
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Smoking Cessation Strategies that Work!

• Treating Tobacco Use and Dependence
• US PHS Clinical Practice Guideline, June 2000

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Major Findings and Panel
Recommendations

• 1. Tobacco dependence is a chronic condition that
  often requires repeated intervention. However,
  effective treatments exist that can produce
  long-term or even permanent abstinence.

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Major Findings and Panel Recommendations

• 2. Because effective tobacco dependence
  treatments are available, every patient who uses
  tobacco should be offered one or more of these
  treatments.

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Major Findings and Panel Recommendations

• 3. It is essential that clinicians and health
  care delivery systems institutionalize the
  consistent identification, documentation, and
  treatment of every tobacco user seen in a health
  care setting.

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Major Findings and Panel Recommendations

• 4. Brief tobacco dependence treatment is
  effective, and every patient who uses tobacco
  should be offered at least brief treatment.

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Major Findings and Panel Recommendations

• 5. There is a strong dose-response relation
  between the intensity of tobacco dependence
  counseling and its effectiveness. Treatments
  involving person-to-person contact (via
  individual, group, or proactive telephone
  counseling) are consistently effective, and their
  effectiveness increases with treatment intensity
  (e.g., minutes of contact).

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Major Findings and Panel Recommendations

• 6. Three types of counseling and behavioral
  therapies were found to be especially effective
  and should be used with all patients attempting
  tobacco cessation
• Provision of practical counseling
  (problem-solving/skills training)
• Provision of social support as part of treatment
  (intra-treatment social support)
• Help in securing social support outside of
  treatment (extra-treatment social support)

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Major Findings and Panel Recommendations

• 7. Numerous effective pharmacotherapies for
  smoking cessation now exist. Five first-line
  pharmacotherapies were identified that reliably
  increase long-term smoking abstinence rates

• Bupropion SR
• Nicotine gum
• Nicotine inhaler

• Nicotine nasal spray
• Nicotine patch

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Major Findings and Panel Recommendations

• 7. Continued
• Two second-line pharmacotherapies were identified
  as efficacious and may be considered by
  clinicians if first-line pharmacotherapies are
  not effective
• Clonidine
• Nortriptyline
• Over-the-counter nicotine patches are effective
  relative to placebo, and their use should be
  encouraged

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Major Findings and Panel Recommendations

• 8. Tobacco dependence treatments are both
  clinically effective and cost-effective relative
  to other medical and disease prevention
  interventions. As such, insurers and purchasers
  should ensure that
• All insurance plans include as a reimbursed
  benefit the counseling and pharmacotherapeutic
  treatments identified as effective in this
  Guideline
• Clinicians are reimbursed for providing tobacco
  dependence treatment just as they are reimbursed
  for treating other chronic conditions

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Clinical Interventions

• The 5 As for patients willing to make a quit
  attempt
• The 5 Rs for patients unwilling to make a quit
  attempt at this time
• Relapse prevention for patients who have recently
  quit
• Intensive interventions should be provided
  when possible
• Health care administrators, insurers, and
  purchasers should institutionalize guideline
  findings

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The 5 As For Patients Willing to Quit

• ASK about tobacco use
• ADVISE to quit
• ASSESS willingness to make a quit attempt
• ASSIST in quit attempt
• ARRANGE for followup

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Elements of a Counseling Intervention

• Quit date
• Set a stop date, preferably within 2 weeks
• Starting on the quit date, total abstinence is
  essential
• Review Past quit experiences
• Anticipate triggers or challenges in upcoming
  attempt

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Elements of a Counseling Intervention (contd)

• Alcohol
• Since alcohol can cause relapse, the patient
  should consider limiting/abstaining from alcohol
  while quitting
• Other smokers in the household
• Quitting is more difficult when there is another
  smoker in the household
• Patients should encourage housemates to quit with
  them or not smoke in their presence

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The 5 Rs to Enhance Motivation for Patients
Unwilling To Quit

• RELEVANCE Tailor advice and discussion to each
  patient
• RISKS Discuss risks of continued smoking
• REWARDS Discuss benefits of quitting
• ROADBLOCKS Identify barriers to quitting
• REPETITION Reinforce the motivational message
  at every visit

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So..

• Smoking cessation reduces mortality and effective
  smoking cessation interventions exist.
• Are smokers receiving these interventions in
  primary care practices?
• What can we do to get more smokers to quit?

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Why Primary Care Practice?

• Most Americans see a primary care clinician
• 60 of outpatient visits
• Teachable moments
• Relationships developed over time and multiple
  encounters

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Competing Demands Theory

• Many worthwhile services compete with each other
  for time on the agenda of primary care patient
  visits.
• When primary care clinicians are not doing one
  activity under scrutiny (e.g. smoking cessation
  counseling), they may be doing something else
  that is more compelling.
• Jaén CR, Stange KC, Nutting PA. The competing
  demands of primary care A model for the delivery
  of clinical preventive services. J Fam Pract.
  1994 38166-171.
• Stange KC, Fedirko T, Zyzanski SJ, Jaén CR.
  How do family physicians prioritize delivery of
  multiple preventive services? J Fam Pract.
  1994 38231-237.

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Two Studies in Primary Care

• The Direct Observation of Primary Care Study
  (DOPC)
• Funded by the National Cancer Institute (NCI)
• Prevention and Competing Demands
• Funded by Agency for Healthcare Research and
  Quality (AHRQ) formerly known as AHCPR

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Direct Observation of Primary Care (DOPC)

• Methods
• More than 4000 visits directly observed by
  research nurses.
• Every 20 seconds up to 15 behaviors coded
• 80 family practice offices in Northeastern Ohio
• Patient exit surveys, chart reviews, practice
  assessments
• Multimethod (qualitative and quantitative
  approaches)
• Stange KC, Zyzanski SJ, Jaén CR, et al.
  Illuminating the black box A description of
  4454 patient visits to 138 family physicians. J
  Fam Pract, 1998 46377-389.

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Time for Tobacco Counseling

• 55 of well care visits
• 22 of illness visits
• More common during visits for tobacco-related
  chronic illness vs. a visit for another chronic
  disease (32 vs. 17)
• Average duration of advice lt1.5 minutes
• Context of counseling not clear
• Jaén CR, Crabtree BF, Zyzanski SJ, Stange KC.
• Making time for tobacco counseling. J Fam Pract,
  199846425-428.

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Prevention and Competing Demands Study

• Multimethod comparative case study design in
  Nebraska
• Direct observation and detailed descriptions of
  1624 encounters by 50 clinicians in 18 family
  practices
• In-depth interview of clinicians, office staff
  and community residents
• Medical record review
• Patient exit questionnaires

Crabtree BF. Miller WL. Stange KC. Understanding
practice from the ground up. Journal of Family
Practice. 50(10)881-7, 2001
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Competing Demands and Tobacco Counseling

• Hierarchy of taken missed opportunities
• Good (5As) counseling 21
• Competing demands 24
• Failure in a non-smoking related visit 27
• Failure in a smoking-related visit 25
• Failure in a health maintenance visit 2
• Guidelines to counsel every visit unrealistic
• Systems individual approaches are needed
• Jaén CR, McIlvain H, Pol L, Phillips RL, Flocke
  SA, Crabtree BF. Tailoring tobacco counseling to
  the competing demands in the clinical encounter.
  J Fam Pract, 2001 50859-863.

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New Theoretical Framework

• Complexity Science
• Primary care practices are complex adaptive
  systems facing the need to respond to internal
  and external uncertainty and surprise. For
  clinicians and practices to maximize their
  ability to proactively evolve as they respond to
  uncertainty and surprise, they need to understand
  that their practices are nonlinear systems and
  create the time and space for learning and
  reflection.

Crabtree BF. Primary Care Practices are Full of
Surprises Health Care Management Review.
28(3)279-83, 2003 Miller WL. McDaniel RR Jr.
Crabtree BF. Stange KC. Practice jazz
understanding variation in family practices using
complexity science. Journal of Family Practice
50(10)872-8, 2001
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Future Research

• How can primary care practices be re-designed to
  improve delivery of smoking cessation services?
• What can be done to improve integration of
  community and practice resources?
• How can counseling for multiple health behaviors,
  e.g. tobacco and problem drinking be integrated
  into practices?

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A RWJF and AHRQ Program
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In Summary

• Research regarding the treatment of tobacco use
  and dependence continues to grow exponentially.
• The challenge is translation - ensuring that the
  practice of treating tobacco use and dependence
  keeps pace with the research.