‹#›
![](3D"master104_image001.gif")
How
to Help Smokers Quit: Clinical Evidence and Policy Implications
Steven A. Schroeder, MD
UCSF GME Grand Rounds
Jan 20, 2009
![](3D"master28_image002.gif")
UCSF Pioneers in Smoking Cessation
<=
span
style=3D'color:yellow;text-shadow:auto;visibility:hidden'>n
--Karen
Hudmon, Lisa Kroon, Robin Corelli
<=
span
style=3D'color:yellow;text-shadow:auto'>nNicotine metabolism—Neal Benowitz
nCessation and mental illness—Sharon Hall and Jodi Prochaska
<=
span
style=3D'color:yellow;text-shadow:auto'>nTobacco policy interventions—Stan Glantz=
T=
opics
for Today
nFacts about smoking
=
nNicotine and dependence
nAids for cessation
<=
/div>
nTelephone quitlines
=
nNext steps
Tobacco’s De=
adly
Toll
n435,000 deaths in the U.S. each year
=
n4.8 million deaths world wide each year&#=
13;
n10 million deaths estimated by year 2030&=
#13;
<=
span
style=3D'mso-special-format:bullet;position:absolute;left:-3.93%;top:.22em;
font-family:Wingdings;font-size:80%'>n50,000 deaths in the
U.S. due to second-hand smoke exposure
n8.6 million disabled from tobacco in the =
U.S.
alone
<=
span
style=3D'text-shadow:auto;mso-special-format:lastCR;display:none'>
![](3D"slide0248_image004.jpg")
![3Dimage002](3D"slide0233_image006.gif")
![](3D"slide0184_image007.gif")
Annual U.S. Deaths Attributable to =
Smoking,
1997–2001
Centers
for Disease Control and Prevention. MMWR <=
/span>2005;54:625=
211;628.
31%
28%
23%
9%
8%
<1%
TOTAL: 437,902 deaths annually
Cardiovascular diseases
137,979
Lung cancer
123,836
=
Respiratory
diseases
101,454
=
Second-hand
smoke
38,112
=
Cancers
other than lung
34,693
=
Other
1,828
Health Consequence=
s of
Smoking
U.S. Department of
Health and Human Services.
The Health
Consequences of Smoking: A Report of the Surgeon General, 2004.
n=
Cancers
–=
;Acute myeloid leukemia
–=
;Bladder and kidney
–=
;Cervical
–=
;Esophageal
–=
;Gastric
–=
;Laryngeal
–=
;Lung
–=
;Oral cavity and pharyngeal
–=
;Pancreatic
Pulmonary diseases
–=
;Acute (e.g., pneumonia)
–=
;Chronic (e.g., COPD)
n=
Cardiovascular
diseases
<=
span
style=3D'font-size:79%;color:#FFE701;mso-color-index:6;text-shadow:auto'><=
span
style=3D'mso-special-format:bullet;color:white;mso-color-index:1;position:=
absolute;
left:-7.32%'>–=
Abdominal
aortic aneurysm
<=
span
style=3D'font-size:79%;color:#FFE701;mso-color-index:6;text-shadow:auto'><=
span
style=3D'mso-special-format:bullet;color:white;mso-color-index:1;position:=
absolute;
left:-7.32%'>–=
Coronary
heart disease
<=
span
style=3D'font-size:79%;color:#FFE701;mso-color-index:6;text-shadow:auto'><=
span
style=3D'mso-special-format:bullet;color:white;mso-color-index:1;position:=
absolute;
left:-7.32%'>–=
Cerebrovascular
disease
<=
span
style=3D'font-size:79%;color:#FFE701;mso-color-index:6;text-shadow:auto'><=
span
style=3D'mso-special-format:bullet;color:white;mso-color-index:1;position:=
absolute;
left:-7.32%'>–=
Peripheral
arterial disease
<=
span
style=3D'font-size:79%;color:#FFE701;mso-color-index:6;text-shadow:auto'><=
span
style=3D'mso-special-format:bullet;color:white;mso-color-index:1;position:=
absolute;
left:-7.32%'>–=
Type
2 diabetes mellitus
nReproductive effects
<=
span
style=3D'font-size:79%;color:#FFE701;mso-color-index:6;text-shadow:auto'><=
span
style=3D'mso-special-format:bullet;color:white;mso-color-index:1;position:=
absolute;
left:-7.32%'>–=
Reduced
fertility in women
–Poor pregnancy outcomes (e.g., low birth weight, preterm delivery)
<=
span
style=3D'font-size:79%;color:#FFE701;mso-color-index:6;text-shadow:auto'><=
span
style=3D'mso-special-format:bullet;color:white;mso-color-index:1;position:=
absolute;
left:-7.32%'>–=
Infant
mortality
n=
Other
effects: cataract, osteoporosis, periodontitis, poor surgical outcomes, c=
ognitive
decline
Smoking and Typ=
e 2
Diabetes*
<=
span
style=3D'font-size:88%;color:#FFE701;mso-color-index:6;text-shadow:auto'><=
span
style=3D'mso-special-format:bullet;position:absolute;left:-3.8%;top:.22em;
font-family:Wingdings;font-size:80%'>nJAMA meta-analysis a=
nd
editorial, Dec 12, 2007
<=
span
style=3D'font-size:88%;color:#FFE701;mso-color-index:6;text-shadow:auto'><=
span
style=3D'mso-special-format:bullet;position:absolute;left:-4.43%;top:.22em;
font-family:Wingdings;font-size:80%'>nConservative relative
risk of 1.44
<=
span
style=3D'font-size:88%;color:#FFE701;mso-color-index:6;text-shadow:auto'><=
span
style=3D'mso-special-format:bullet;position:absolute;left:-4.43%;top:.22em;
font-family:Wingdings;font-size:80%'>n12% of diabetes
attributable to smoking
n=
D=
espite
lower weight in smokers, more central a=
diposity
n=
S=
moking
also increases inflammation, oxidative s=
tress,
and impairs endothelial function
n=
S=
moking
cessation should be a key facet of diabetes prevention and
treatment
<=
span
style=3D'font-size:50%;text-shadow:auto;color:#FFE701;mso-color-index:6'>*=
Willi et al JAMA 2007;298:2654-64=
; Ding
and Hu editorial 2675-76
<=
span
style=3D'text-shadow:auto;mso-special-format:lastCR;display:none'>
![3Dimage002](3D"slide0243_image009.gif")
![](3D"slide0229_image011.gif")
![3D"Text](3D"slide0229_image012.gif")
=
Age at cessation (years)
nProspective study of 34,439 male British doctors
<=
span
style=3D'font-family:Tahoma'>nMortality was monitored for 50 years
(1951–2001)
Smoking Cessation:
= Reduced Risk of Death
= Reduced Risk of Death
Doll
et al. (2004). BMJ 328(7455):1519–1527.
![](3D"slide0207_image015.gif")
n
Reduction in =
cumulative risk of =
death from lung =
cancer in men
Reprinted with permission. Peto et al. (2000). =
BMJ 321(7257):323–329.
![](3D"slide0207_image017.jpg")
![3D"Text](3D"slide0207_image018.gif")
=
![](3D"slide0207_image019.gif")
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Age in years
Smoking and Mental Illness: The Heavy Burden
n=
2=
00,000
of the 435,000 annual deaths from smoking o=
ccur
among patients with CMI and/or substance abuse
n=
T=
his
population consumes 44% of all cigarettes sold in =
t=
he
United States
--h=
igher
prevalence
--s=
moke
more
--m=
ore
likely to smoke down to the butt
nP=
eople
with CMI die on average 25 years earlier than o=
thers,
and smoking is a large contributor to that early =
m=
ortality
n=
S=
ocial
isolation from smoking compounds the social =
s=
tigma
Causal Association=
s with
Second-hand Smoke
Second-hand Smoke
nDevelopmental
–Low birthweight
–=
;Pre=
-term
delivery
–
nRespiratory
–Eye and nasal irritation
n=
=
;
n&#=
13;
nCarcinogenic
–Lung cancer
–Nasal sinus cancer
n
nCardiovascular
–=
;Hea=
rt
disease mortality
–=
;Alt=
ered
vascular properties
Compounds in Tobac=
co
Smoke
–Carbon monoxide
=
–Hydrogen cyanide
=
;
–<=
/span>Ammonia
–<=
/span>Benzene
–<=
/span>Formaldehyde
–Nicotine
=
–Nitrosamines
–<=
/span>Lead
–<=
/span>Cadmium
–<=
/span>Polonium-210
=
An estimated 4,800 compounds in to=
bacco
smoke, including 11 proven hu=
man
carcinogens
![3Dj0104534](3D"slide0113_image023.gif")
![](3D"slide0113_image024.gif")
Gases
Particles
![](3D"slide0113_image025.gif")
| Tobacc=
o smoke, which
is inhaled either directly or as second-hand smoke, contains an estimated
4,800 compounds. The majority of the compounds are present in the particu=
late
phase, suspended in tobacco smoke. Based on a classification system by the
International Agency for Research on Cancer, cigarette smoke contains 11
known human carcinogens (Group I), 7 probable human carcinogens (Group 2A=
),
and 49 animal carcinogens that possibly also are carcinogens in humans (G=
roup
2B) (NCI, 2001). |
||
| Exampl=
es of
detrimental compounds (some of which are carcinogens) in tobacco smoke
include the following: |
||
| Carbon=
monoxide:
automobile exhaust; binds to hemoglobin, inhibits respiration |
||
| Hydrog=
en cyanide:
gas chamber poison; highly ciliotoxic, inhibits lung clearance |
||
| Ammoni=
a:
floor/toilet cleaning agent; irritation of respiratory tract |
||
| Nicoti=
ne : addictive
substance; toxic alkaloid |
||
| Benzen=
e: solvent,
banned substance in organic chemistry labs; Group I carcinogen |
||
| Nitros=
amines:
carcinogenic in animals and probably in humans; Group 2A and 2B carcinogens |
||
| Lead: =
heavy metal,
toxic to central nervous system; Group 2B carcinogen |
||
| Cadmiu=
m: heavy metal
found in rechargeable batteries; Group I carcinogen |
||
| Hexava=
lent chromium:
highlighted in the movie Erin Brockovich; Group I carcinogen |
||
| Arseni=
c: pesticide;
Group I carcinogen |
||
| Poloni=
um-210:
radioactive agent; Group I carcinogen |
||
| Formal=
dehyde:
embalming fluid; Group 2B carcinogen |
||
| Other =
substances in
tobacco smoke (not listed above) with sufficient evidence to be classifie=
d as
Group I carcinogens in humans include 2-naphthylamine, 4-aminobiphenyl, v=
inyl
chloride, ethylene oxide, beryllium, and nickel. |
||
| =
834; Note
to instructor(s): It is important to emphasize that although nicotine=
is
the addictive component of tobacco, it does not cause the ill heal=
th
effects. |
||
| Nation=
al Cancer
Institute (NCI). (2001). Risks Associated with Low Machine-Measured Yi=
elds
of Tar and Nicotine (NIH Publication No. 02-5074). Smoking and
Tobacco Control Monograph No. 13. Bethesda, MD: U.S. Department of Health=
and
Human Services, National Institutes of Health, National Cancer Institute.=
|
||
| Slide =
is used with
permission, Rx for Change: Clinician-Assisted Tobacco Cessation. Copyright
© 1999-2007 The Regents of the University of California, University =
of
Southern California, and Western University of Health Sciences. All rights
reserved. |
||
The Real Culprit
n=
I=
t is
the smoke, tar, and additives that make p=
eople
sicken and die.
n=
N=
icotine
is dangerous because it leads to addiction, and therefore
increased exposure tobacco constituents.
n=
T=
herefore,
nicotine replacement therapy is helpful, not harmful. It=
is
a “clean” form of nicotine.<=
/div>
TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2005&#=
13;
Trends in cigarette current smoking among persons aged 18 or older
Graph provided by the Centers for Disease
Control and Prevention. 1955 Current Population =
Survey; 1965–2005 NHIS. Estimates since 1992 include some-day smoking.=
![3D"Text](3D"slide0193_image026.gif")
![](3D"slide0193_image027.gif")
70%
want to quit
![](3D"slide0193_image029.gif")
![](3D"slide0193_image030.gif")
Male
Female
23.9%
18.1%
Year
![3DCDCW2](3D"slide0193_image032.gif")
TRENDS in ADULT
CIGARETTE CONSUMPTION—U.S., 1900 <=
span
lang=3DEN-US style=3D'font-size:91%;color:#FFE701;mso-color-index:6;mso-an=
si-language:
EN-US'>–2005
Annual adult per capita cigarette consumption and major smoking and
health events
Centers for Disease
Control and Prevention. (1999). MMWR 48:986–993.
Per-capita updates=
from
U.S. Department of Agriculture, provided by the American Cancer Society.
![3DCDCW2](3D"slide0234_image033.gif")
![](3D"slide0234_image035.gif")
![](3D"slide0234_image036.gif")
First
Surgeon
General’s
Report
Great
Depression
End
of WW II
![](3D"slide0234_image037.gif")
![](3D"slide0234_image038.gif")
![](3D"slide0234_image039.gif")
![](3D"slide0234_image040.gif")
Federal
cigarette
tax do=
ubles
![](3D"slide0234_image041.gif")
Master&=
#13;
Settlem=
ent
Agreement;
California =
first state to enact
ban on smoking in =
bars
Broadc=
ast
ad ban=
![](3D"slide0234_image042.gif")
=
Cigarette price
drop
![](3D"slide0234_image043.gif")
Nonsmokers’
rights
movement
begins
![3D"Text](3D"slide0234_image044.gif")
Year
=
20 states have
> $1 pack tax
![](3D"slide0234_image045.gif")
U.S. Cigarette Consumption and U=
.S.
Smoking Prevalence 1965-2007
![](3D"slide0250_image047.gif")
![](3D"slide0249_image049.gif")
![](3D"slide0249_image050.gif")
Calif=
ornia
14.9%=
New Yo=
rk
18.3%=
Utah&=
#13;
9.8%=
Texas
18.1%=
Illin=
ois
20.5%=
![](3D"slide0249_image051.gif")
Ke=
ntucky
28=
.6%
Nevad=
a
22.2%
![](3D"slide0249_image052.gif")
Centers for Disease Control and Prevention. (2007). MMWR
56(38), 993-996.
Flori=
da
21.0%<=
/div>
![](3D"slide0249_image053.gif")
India=
na
24.1%<=
/div>
![](3D"slide0249_image054.gif")
STATE=
-SPECIFIC
PREVALENCE of SMOKING among ADULTS, 2006
![](3D"slide0217_image055.gif")
TRENDS in TEEN SMOKING, by ETHNICITY—U.S., 1977–2006
Trends in cigarette smoking among 12th graders: 30-day prevalence of =
use
![](3D"slide0217_image057.gif")
Institute for Social Research, University of Michigan,
Monitoring the Future Project
www.monitoringthefuture.org
![3D"Text](3D"slide0217_image058.gif")
White
Hispanic
Black
PREVALENCE of ADULT SMOKING,
by RACE/ETHNICITY—U.S., 2= 005
by RACE/ETHNICITY—U.S., 2= 005
![](3D"slide0215_image060.gif")
![](3D"slide0215_image061.gif")
13.3% Asian*
![](3D"slide0215_image062.gif")
32.0%
American Indian/Alaska Native*
![](3D"slide0215_image063.gif")
21.5% Black*
21.9% White*
16.2% Hispanic
Centers for Disea=
se
Control and Prevention. (2006). MMWR
55:1145–1148.
* non-Hispanic.
PREVALENCE of ADULT SMOKING,
by EDUCATION—U.S., 2005
by EDUCATION—U.S., 2005
![](3D"slide0216_image065.gif")
![](3D"slide0216_image066.gif")
10.7% Undergraduate degree
![](3D"slide0216_image067.gif")
25.5% No high school diploma
43.2% GED diploma
24.6% High school graduate
22.5% Some college
7.1% Graduate degree
Centers for Disea=
se
Control and Prevention. (2006). MMWR
55:1145–1148.
Number
of Smokers =3D
New Smokers + Old Smokers - Quitters
New Smokers + Old Smokers - Quitters
![](3D"slide0213_image068.gif")
Number of Quitters =3D
Number of Quit Attempts X % of Quitters
![](3D"slide0213_image069.gif")
![](3D"slide0213_image070.gif")
Price