UTAH, THE US, AND NICOTINE: UPDATE Sarah Woolsey, MD, FAAFP Medical Director HealthInsight Utah, and CHC, Inc.

Transcription

1 UTAH, THE US, AND NICOTINE: UPDATE 2016 Sarah Woolsey, MD, FAAFP Medical Director HealthInsight Utah, and CHC, Inc.

2 A cigarette is the only consumer product which when used as directed kills its consumer. - Dr. Gro Harlem Brundtland Former WHO Director General

3 No conflicts of interest DISCLOSURE

4 LEARNING OBJECTIVES Understand current tobacco and electronic cigarette usage rates in Utah and the US Utilize evidence-based techniques for smoking cessation interventions with patients and families Understand how to integrate free cessation services into your clinical setting

5 BY THE NUMBERS

6 UTAH AND US NICOTINE ADDICTION: BY THE NUMBERS UT US Deaths/year 1, ,000 Conventional Use 9.50% 16.80% E-cig Use 4.80% 3.70% Smokers that want to quit in next 12 months 73% 68.90% Population (2014) million million TOBACCO PREVENTION AND CONTROL IN UTAH Fifteenth Annual Report, August

7 DISPARITIES AMONGST US ADULTS WHO SMOKE CIGARETTES, 2014 Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults United States, Morbidity and Mortality Weekly Report 2015;64(44):

8 DISPARITIES AMONGST UTAH ADULTS WHO SMOKE CIGARETTES, 2013 AND 2014 * These estimates have a relative standard error of >30% and do not meet UDOH standards for reliability TOBACCO PREVENTION AND CONTROL IN UTAH Fifteenth Annual Report, August 2015

9 PREGNANCY AND SMOKING IN US, 2010 In 2010, data from 27 sites, representing 52% of live births reported by CDC 23% of women reported smoking in the 3 months prior to pregnancy 54.3% reported that they quit smoking by the last 3 months of pregnancy Almost 11% reported smoking during the last 3 months of pregnancy Almost 16% reported smoking after delivery Centers for Disease Control and Prevention. Trends in Smoking Before, During, and After Pregnancy Pregnancy Risk Assessment Monitoring System, United States, 40 Sites, Morbidity and Mortality Weekly Report 2013;62(SS06)1 19 [accessed 2015 Dec 7].

10 UTAH PREGNANCY NUMBERS Percent of Utah Women Who Smoked Before, During, and after Pregnancy, % 15% 10% 5% Smoked 3 months before pregnancy Smoked last 3 months of pregnancy Smoke now 0% Smoked 3 months before pregnancy 14.3% 14.3% 13.8% 13.6% 11.5% 12.3% 10.2% 12.2% 10.6% 10.4% 13.1% 11.8% 11.3% Smoked last 3 months of pregnancy 6.2% 7.3% 7.7% 6.8% 3.9% 6.6% 5.1% 6.1% 5.3% 5.1% 5.9% 4.5% 4.0% Smoke now 9.3% 9.5% 10.1% 9.0% 7.7% 8.7% 7.3% 8.3% 7.6% 7.1% 8.0% 7.2% 6.3% Department of Health.

11 COST OF SMOKING Smoking-related illness in the United States costs more than $300 billion a year $170 billion in direct medical care for adults $156 billion in lost productivity Secondhand smoke costs our economy $5.6 billion per year due to lost productivity In 2012, $9.17 billion spent on advertising and promotion of cigarettes >$25 million daily U.S. Department of Health and Human Services. The Health Consequences of Smoking 50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Federal Trade Commission. Federal Trade Commission Cigarette Report for 2012[PDF 308 KB]. Washington: Federal Trade Commission, 2015

12 ESTIMATED ANNUAL COST OF SMOKING IN UTAH TOBACCO PREVENTION AND CONTROL IN UTAH Fifteenth Annual Report, August

13 NICOTINE ADDICTION & YOUTH In 1981, a Philip Morris report had the following to say about tobacco & teenagers: Today s teenager is tomorrow s potential regular customer. The smoking patters of today s teenager are particularly important to Philip Morris. -PM Industry Document, 1981 Nicotine addiction is a pediatric epidemic: nearly 90% of adult smokers started before the age of 18 AAP. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. AAP; Benowitz NL, Goniewicz ML. JAMA. 2013;310: Grana R, et al. Circulation. 2014;129:

14 NICOTINE AND YOUTH: BY THE NUMBERS From 2011 to 2014, conventional cigarette smoking declined among middle and high school students In % of middle school students reported smoking cigarettes in the past 30 days a decrease from 4.3% in % of high school students reported smoking cigarettes in the past 30 days a decrease from 15.8% in 2011 In 2014, 1.6% of middle school students and 5.5% of high school students reported current use of smokeless tobacco CONCERN: These forms have been replaced with ENDS (e-cigarette) use Centers for Disease Control and Prevention. Tobacco Use Among Middle and High School Students United States, Morbidity and Mortality Weekly Report, 2015;64(14):381 5

15 NICOTINE ADDICTION AND UTAH YOUTH In Utah in 2014, 5.6% of individuals under the age of 18 reported that they currently smoke cigarettes Preliminary results show tobacco use rates in alternative schools are significantly higher than the rates found in regular public schools: 27.5% of students in the alternative high school sample reported current cigarette smoking compared to 3.4% of students in regular public schools CDC Youth Online: High School YRBS TOBACCO PREVENTION AND CONTROL IN UTAH Fifteenth Annual Report, August

16 NICOTINE ADDICTION AND YOUTH: BY THE NUMBERS (CONT D) Electronic cigarette use among Utah youth nearly doubled from 2013 (5.8%) to 2015 (10.5%) and is more than twice as high as adult use Nearly one quarter (22.9%) of Utah students in grades 8, 10, and 12 have tried e-cigarettes TOBACCO PREVENTION AND CONTROL IN UTAH Fifteenth Annual Report, August

17 YOUTH TOBACCO USE BY PRODUCT TYPE (2015) Tobacco Prevention and Control Program. Prevention Needs Assessment Tobacco Questions, 2013 and Salt Lake City: Utah Department of Health TOBACCO PREVENTION AND CONTROL IN UTAH Fifteenth Annual Report, August 2015

18 SECONDHAND SMOKE: BY THE NUMBERS Secondhand Smoke (SHS) contains over 7,000 chemicals, hundreds of toxins, and more than 70 carcinogens 30% increase in the chance of heart attack with long-term exposure and a 20% increase in the chance of lung cancer 45,000 Americans die annually from secondhand smoke From , 58 million nonsmokers in the United States were exposed to secondhand smoke Children who live in multi-unit housing have 45% higher cotinine levels than children who live in single-family homes 2 out of 5 children ages 3 to 11 including 7 out of every 10 Black children in the United States were exposed to secondhand smoke regularly During , more than 1 in 3 (36.8%) nonsmokers who lived in rental housing were exposed to secondhand smoke CDC. 50 years of progress: A report of the Surgeon General, CDC, US DHS, 2014

19 SECONDHAND SMOKE 38.8% of Utah adults reported breathing SHS in the past week at indoor or outdoor locations In 2014, nearly 17,000 Utah children were exposed to SHS inside their homes during the past week TOBACCO PREVENTION AND CONTROL IN UTAH Fifteenth Annual Report, August

20 THIRDHAND SMOKE Thirdhand Smoke is defined as the lingering residue and odor that burned tobacco products deposit onto clothing, hair and other surfaces Within this residue, measurable amounts of carcinogens are left on surfaces Carcinogens can also even be detected in children s urine following exposure No Numbers on this one Martins-Green M, et al. PloS one. 2014;9:e86391., Thomas JL, et. al, Nicotine Tob Res, 2013; Hang B, et al., Mutagenesis 2013;28: Thomas JL, Cancer Epidemiol Biomarkers Prev. 2011;20:

21 ENDS

22 ELECTRONIC NICOTINE DELIVERY SYSTEMS Electronic cigarette e-cigarette, hookah stick Electronic nicotine delivery device Nicotine liquid Juice Vaping Delivers more nicotine than regular cigarette

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24 ELECTRONIC CIGARETTES ARE THE NEW PATHWAY TO NICOTINE ADDICTION CDC and FDA studies have shown youth use of e- cigarettes tripled from Current e-cigarette use among high school students 1.5% in % in % in % high schoolers and 11.8% of middle schoolers were frequent users of e-cigarettes (20/30 days in past month) Among 10th graders, 16.2% reported using an e- cigarette and 7.2% reported using a traditional cigarette U.S. Centers for Disease Control and Prevention (CDC), Tobacco Use Among Middle and High School Students United States, , Morbidity and Mortality Weekly Report (MMWR) 64(14): , April 2015,

25 ELECTRONIC CIGARETTES ARE THE NEW PATHWAY TO NICOTINE ADDICTION (UT) Since 2013, Utah youth use rates have doubled despite the law prohibiting sales to minors under the age of 19 10% youth < 18yrs reported e cigarette use in past 30 days in % reported use in 2013 Nearly one-third of Utah teens who used e-cigarettes in the past 30 days have never tried a conventional cigarette In 2015, Utah teens used traditional tobacco at a rate of 3.4% A recent Utah study showed that vape and tobacco specialty stores are most likely to sell to teens Electronic Cigarettes in Utah

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29 WHAT ADULTS ARE USING E-CIGARETTES? In 2014, 12.6% of adults had ever tried an e-cigarette 3.2 % of adults who had never smoked, 9.7% in age range yrs. About 3.7% of adults currently use e-cigarettes Current cigarette smokers and former smokers who quit smoking within the past year were most likely to use e-cigarettes Among current cigarette smokers who had tried to quit smoking in past 12 months >50% had ever tried an e-cigarette 20.3% were current e-cigarette users. Schoenborn CA, Gindi RM. Electronic cigarette use among adults: United States, NCHS data brief, no Hyattsville, MD: National Center for Health Statistics

30 Schoenborn CA, Gindi RM. Electronic cigarette use among adults: United States, NCHS data brief, no Hyattsville, MD: National Center for Health Statistics

31 Schoenborn CA, Gindi RM. Electronic cigarette use among adults: United States, NCHS data brief, no Hyattsville, MD: National Center for Health Statistics

32 WHAT UTAH ADULTS ARE USING E-CIGARETTES? Nearly 60% of current e-cigarette users also smoke cigarettes Nearly 15% of current e-cigarette users have never smoked a conventional cigarette While adult e-cigarette use rates have risen sharply in the past two years, cigarette smoking rates have remained mostly unchanged Electronic Cigarettes in Utah

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34 WHAT ARE THE KNOWN HEALTH EFFECTS? May deliver Nicotine=Highly addictive Few safety or advertising regulations Marketed with potential for smoking cessation Emissions Lower toxins found than in a traditional cigarette, but higher levels than what is found in a nicotine replacement therapy product Unknown what frequent, routine inhalation of propylene glycol and flavoring agents will do to lung tissue Benowitz NL, Goniewicz ML. JAMA. 2013;310: Goniewicz ML, et al. Tob. Control. 2014;23: Kosmider L, et al. Nicotine Tob Res. 2014;16: Grana R, et al. Circulation. 2014;129:

35 ARE THEY A CESSATION AID? As of September 2015 USPTF does not support them as a cessation tool They are not FDA approved And E-cigarettes may alleviate the desire to smoke cigarettes and reduce consumption and/or enable short periods of cessation Cochrane review 2014 Low grade evidence in 2 small trials to reduce long term smoking compared to sham e-cigs May assist patients to cut down but low grade evidence to date Note: Patches and gum differ from e-cigarettes in that they are FDA regulated and administer low doses of nicotine slowly into the body unlike e-cigarettes Schepers JS. Electronic cigarettes: do they have a role in smoking cessation? J Pharm Pract. 2012;25(6): Cochrane Database Syst Rev. Electronic cigarettes for smoking cessation and reduction..2014;12:cd Epub 2014 Dec 17.

36 PEDIATRIC CONCERNS Association between current e-cigarette use and conventional cigarette use among adolescents Poisonings through ingestion, inhalation, or absorption of nicotine liquid on the skin; Child poisonings related to e-cigarettes increased sharply from Dutra LM, Glantz SA. JAMA Pediatrics. 2014;168: TOBACCO PREVENTION AND CONTROL IN UTAH Fifteenth Annual Report, August

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38 WHAT SHOULD I BE SAYING TO MY PATIENTS ABOUT THESE THINGS? Ask about vaping as you screen Use evidence-based smoking cessation methods Smoking Cessation Guidelines do not recommend vaping or e cigs Recommend avoidance of smoked tobacco E-cigs and vaping reinforce the automatic habits of smoking and may hinder quitting E-cigs may deliver higher levels of nicotine to you more rapidly and keep you hooked Follow results of e-cigarette clinical trials Schepers JS. Electronic cigarettes: do they have a role in smoking cessation? J Pharm Pract. 2012;25(6): Knorst et al. J Bras Pneumol Sep-Oct; 40(5):

39 NICOTINE SIDE EFFECTS Nicotine Causes Dependence, body quickly requires more and more for effect Elevation in heat rate and blood pressure Vasoconstriction Elevates respiratory rate Jaw pain, worsen TMJ disorder esp. oral forms Tooth disorders Headache Nausea Hiccups Palpitations, arrhythmia Flatulence, diarrhea Insomnia Chest discomfort Contraindication or Cautions Recent MI CAD Arrhythmias Angina Asthma Peripheral vascular disease Pregnancy Insulin dependent DM HTN Hyperthyroidism Pheochromocytoma Renal impairment

40 HELPING PEOPLE QUIT Ask, Advise, Connect

41 CLINICAL PRACTICE GUIDELINE FOR TREATING TOBACCO USE AND DEPENDENCE May 2008 Sponsored by Agency for Healthcare Research and Quality National Cancer Institute National Institute for Drug Addiction National Heart, Lung, & Blood Institute Robert Wood Johnson Foundation Centers for Disease Control and Prevention

42 AAFP TOOLKIT 2015 Current billing codes EHR tools and workflow tips acco/practice-manual.pdf

43 TOBACCO DEPENDENCE: A TWO PART PROBLEM Tobacco Dependence Physiological The addiction to nicotine Treatment Behavioral The habit of using tobacco Treatment Medications for cessation Behavior change program Treatment should address the physiological and the behavioral aspects of dependence.

44 SMOKING CESSATION MEDICATIONS Nicotine polacrilex gum Nicorette (OTC) Generic nicotine gum (OTC) Nicotine lozenge Commit (OTC) Generic nicotine lozenge (OTC) Nicotine transdermal patch Nicotine nasal spray Nicotrol NS (Rx) Nicotine inhaler Nicotrol (Rx) Bupropion SR (Zyban) Varenicline (Chantix) Nicoderm CQ (OTC) Nicotrol (OTC) Generic nicotine patches (OTC, Rx) These are the only medications that are FDA-approved for smoking cessation.

45 SMOKING INTERVENTIONS BY THE NUMBERS Ask (Screening) Advise (Advice to quit) Outcome measure Abstinence (OR) Quit rate (%, 95% CI) Clinician intervention None System Successful quit attempt None Advice Counseling time None <3 min 3-10 min >10 min Number of interventions Clinician type None/self-help Physician Non-physician Number of clinician types Zero One Two ( ) ( ) ( ) 1.6 ( ) 2.3 ( ) ( ) 1.9 ( ) 1.0/ ( ) 1.7 ( ) ( ) 2.5 ( ) ( ) ( ) ( ) 16.0 ( ) 22.1 ( ) ( ) 20.9 ( ) 10.2/ ( ) 15.8 ( ) ( ) 23.6 ( ) Fiore MC, et al. Treating tobacco use and dependence: 2008 update. CDC, US DHS, 2008.

46 SMOKING INTERVENTIONS BY THE NUMBERS Refer (Referral to treatment resource) Outcome measure Abstinence (OR) Quit rate (%, 95% CI) Referral Type No Referral Self-help Quitline Individual Counseling ( ) 1.2 ( ) 1.7 ( ) ( ) 13.1 ( ) 16.8 ( ) Quitline Minimal/no counseling Quitline ( ) ( ) Counseling Counseling alone Counseling + medication ( ) ( ) Medication Placebo Nicotine patch Nicotine gum Follow up ( ) 2.3 ( ) Expert opinion ( ) 26.1 ( ) Fiore MC, et al. Treating tobacco use and dependence: 2008 update. CDC, US DHS, 2008.

47 ASK, ADVISE, CONNECT Ask (every visit) This can be done by your assistant or office staff If they smoke Are you willing to quit at this time? Gauge how much the person smokes, how long they have smoked for, and if they have any interest in quitting Prompt by Meaningful Use in EHRs (script it) Advise Encourage cessation and ask that all household members quit smoking Simple, clear, personal This is the single best thing we can do to improve your health Connect Use a Proactive referral Fax their contact information to the QuitLine, right there Have them call the QuitLine from your office, right there Document in EHR so you can follow-up Use Reactive referral Provide client with contact information for cessation Vidrine JAMA Intern Med Mar 25;173(6): doi: /jamainternmed

48 QUITTING RESOURCES Telephonic Quitline: QUIT-NOW ( ) Online resources Centers for Disease Control and Prevention How to Quit: Tips From Former Smokers: Quit Smoking: U.S.Department of Health and Human Services Smokefree.gov: SmokefreeTXT:

49 UTAH RESOURCES

50 THE UTAH TOBACCO QUIT LINE QUIT.NOW Also available in Spanish at: phone call visits to support quitting 9 if the caller is pregnant Multilingual: Depending on the time of day, staff is on hand that speaks a wide variety of languages Quitline has NO cost for patient Supported by insurers and Tobacco Settlement monies Free Nicotine Replacement Support for some demographics ACA requires coverage of at least 1 pharmacological and 1 behavioral treatment waytoquit.org/refer-patients

51 QUIT LINE SERVICES RENDERED So far in 2015, 4,409 Utahns from 29 counties have received services from the Utah Tobacco Quit Line or online coaching 31% of Quit Line users were Medicaid clients 36% of Quit Line users were uninsured In 2014, 328 youth received services from the Teen Tobacco Quit Line

52 ONLINE REFERRAL FORM

53 REFERRAL PROCESS Send referral - fax or online Quit Line calls client Client enrolls, receives materials, NRT Client receives quit coaching Outcomes report sent to HIPPA-covered entities

54 UTAH S CESSATION RESOURCES Utah s Online Coaching Found online at Offers all of the same great services as the phone line, but doesn t require patient to call a number and talk to people

55 Detailed information on the quit line and online coaching services Cost Calculator for Quitters Health information about the effects of smoking Active Facebook channel where patients can connect with others who have quit, or are trying to quit for some casual support

56 Waytoquit.org

57 SECOND/THIRDHAND PREVENTION

58 WRAP Despite low rates, Utahns still smoke Rates are as high or higher than US in some populations E-cig use by youth is concerning Policy is not keeping up with market forces Medical Providers are effective agents to support cessation Ask, Advise, Connect them to resources Educate on the risks of e-cigs with your adult and pediatric patients

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60 QUESTIONS AND SHOW AND TELL Sarah Woolsey, MD, FAAFP HealthInsight Utah Thank you to Steve Hanson, MPH Health Educator, Tobacco Prevention and Cessation Salt Lake County Health Department For the Toys

61 THANK YOU