CIGARETTE SMOKING, CARDIOVASCULAR DISEASE RISK, AND IMPLEMENTATION STRATEGIES FOR SMOKING CESSATION...
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CIGARETTE SMOKING, CARDIOVASCULAR CIGARETTE SMOKING, CARDIOVASCULAR DISEASE RISK, AND DISEASE RISK, AND IMPLEMENTATION STRATEGIES FOR IMPLEMENTATION STRATEGIES FOR SMOKING CESSATION SMOKING CESSATION Adapted and Modified from: Adapted and Modified from: Luepker RV, Lando HA. Tobacco Use and Passive Luepker RV, Lando HA. Tobacco Use and Passive Smoking, in: Smoking, in: Wong ND, Black HR, Gardin JM, eds. Preventive Wong ND, Black HR, Gardin JM, eds. Preventive Cardiology, Mc Graw Hill, 2000 and Cardiology, Mc Graw Hill, 2000 and NANCY HOUSTON MILLER, R.N., B.SN., Stanford NANCY HOUSTON MILLER, R.N., B.SN., Stanford University University Roger Blumenthal, MD et al ACC Prevention Roger Blumenthal, MD et al ACC Prevention Guidelines 2007 Guidelines 2007
CIGARETTE SMOKING, CARDIOVASCULAR DISEASE RISK, AND IMPLEMENTATION STRATEGIES FOR SMOKING CESSATION Adapted and Modified from: Luepker RV, Lando HA. Tobacco
CIGARETTE SMOKING, CARDIOVASCULAR DISEASE RISK, AND
IMPLEMENTATION STRATEGIES FOR SMOKING CESSATION Adapted and
Modified from: Luepker RV, Lando HA. Tobacco Use and Passive
Smoking, in: Wong ND, Black HR, Gardin JM, eds. Preventive
Cardiology, Mc Graw Hill, 2000 and NANCY HOUSTON MILLER, R.N.,
B.SN., Stanford University Roger Blumenthal, MD et al ACC
Prevention Guidelines 2007 Adapted and Modified from: Luepker RV,
Lando HA. Tobacco Use and Passive Smoking, in: Wong ND, Black HR,
Gardin JM, eds. Preventive Cardiology, Mc Graw Hill, 2000 and NANCY
HOUSTON MILLER, R.N., B.SN., Stanford University Roger Blumenthal,
MD et al ACC Prevention Guidelines 2007
Slide 2
Smoking Statement Issued in 1956 by American Heart Association
It is the belief of the committee that much greater knowledge is
needed before any conclusions can be drawn concerning relationships
between smoking and death rates from coronary heart disease. The
acquisition of such knowledge may well require the use of
techniques and research methods that have not hitherto been applied
to this problem. Circulation 1960; vol. 23
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Slide 3
Arch Intern Med. 2003;163:23012305. Surgeon Generals Health
Consequences of Smoking, 2004. CDC/NCHS. Tobacco-Related Mortality,
Fact Sheet. CDC.gov/tobacco. February 2004. Heart Disease and
Stroke Statistics2005 Update, AHA. MMWR, Vol. 51, No. 14, 2002,
CDC/NCHS. 33.5% of smoking-related deaths among Americans are
cardiovascular-related Male smokers die an average of 13.2 years
earlier than male nonsmokers Female smokers die an average of 14.5
years earlier than female nonsmokers Current cigarette smoking is a
powerful independent predictor of sudden cardiac death in patients
with CHD Cigarette smoking results in a two- to threefold risk of
dying from CHD Smoking: Mortality
Slide 4
CHD Risk by Cigarette Smoking. Filter Vs. Non-filter.
Framingham Study. Men
Slide 5
Prevalence of current smoking for Adults age 18 and older by
race/ethnicity and sex (NHIS:2004). Source: MMWR. 2004;54:1121-24.
NH non-Hispanic.
Slide 6
Prevalence of high school students in grades 9-12 reporting
current cigarette smoking by race/ethnicity and sex. (YRBS:2005).
Source: MMWR. 2006;55:SS-5. June 9, 2006.. NH non-Hispanic.
Slide 7
TOBACCO USE AS A CARDIOVASCULAR RISK FACTORTOBACCO USE AS A
CARDIOVASCULAR RISK FACTOR OVERVIEW OF SMOKING CESSATION AND THE
IMPORTANCE OF INTERVENING IN CLINICAL PRACTICEOVERVIEW OF SMOKING
CESSATION AND THE IMPORTANCE OF INTERVENING IN CLINICAL PRACTICE
LESSONS LEARNED FROM THE IMPLEMENTATION AND DISSEMINATION OF A
SUCCESSFUL RESEARCH PROGRAM IN HOSPITALIZED PATIENTSLESSONS LEARNED
FROM THE IMPLEMENTATION AND DISSEMINATION OF A SUCCESSFUL RESEARCH
PROGRAM IN HOSPITALIZED PATIENTS INTRODUCING SYSTEM - WIDE CHANGES
FOR SUCCESS WITH CARDIAC AND OTHER HOSPITALIZED PATIENTSINTRODUCING
SYSTEM - WIDE CHANGES FOR SUCCESS WITH CARDIAC AND OTHER
HOSPITALIZED PATIENTS TOBACCO USE AS A CARDIOVASCULAR RISK
FACTORTOBACCO USE AS A CARDIOVASCULAR RISK FACTOR OVERVIEW OF
SMOKING CESSATION AND THE IMPORTANCE OF INTERVENING IN CLINICAL
PRACTICEOVERVIEW OF SMOKING CESSATION AND THE IMPORTANCE OF
INTERVENING IN CLINICAL PRACTICE LESSONS LEARNED FROM THE
IMPLEMENTATION AND DISSEMINATION OF A SUCCESSFUL RESEARCH PROGRAM
IN HOSPITALIZED PATIENTSLESSONS LEARNED FROM THE IMPLEMENTATION AND
DISSEMINATION OF A SUCCESSFUL RESEARCH PROGRAM IN HOSPITALIZED
PATIENTS INTRODUCING SYSTEM - WIDE CHANGES FOR SUCCESS WITH CARDIAC
AND OTHER HOSPITALIZED PATIENTSINTRODUCING SYSTEM - WIDE CHANGES
FOR SUCCESS WITH CARDIAC AND OTHER HOSPITALIZED PATIENTS
Slide 8
SMOKING: THE FACTS FIFTY MILLION AMERICANS SMOKE (1 IN 4
ADULTS)FIFTY MILLION AMERICANS SMOKE (1 IN 4 ADULTS) FIFTY PERCENT
ATTEMPT TO QUIT ANNUALLYFIFTY PERCENT ATTEMPT TO QUIT ANNUALLY ONLY
42% OF M.I. SMOKERS RECEIVED SMOKING CESSATION INTERVENTIONS AT
HOSPITAL DISCHARGE (NRMI II)ONLY 42% OF M.I. SMOKERS RECEIVED
SMOKING CESSATION INTERVENTIONS AT HOSPITAL DISCHARGE (NRMI II)
ONLY 21% OF SMOKERS RECEIVED COUNSELING @ CLINIC VISITS (1995)ONLY
21% OF SMOKERS RECEIVED COUNSELING @ CLINIC VISITS (1995) TREATMENT
IS MOST OFTEN OFFERED TO THOSE WITH TOBACCO-RELATED
DISEASESTREATMENT IS MOST OFTEN OFFERED TO THOSE WITH
TOBACCO-RELATED DISEASES DIRECT/INDIRECT MEDICAL COSTS APPROACH
$130 BILLION ANNUALLYDIRECT/INDIRECT MEDICAL COSTS APPROACH $130
BILLION ANNUALLY FIFTY MILLION AMERICANS SMOKE (1 IN 4 ADULTS)FIFTY
MILLION AMERICANS SMOKE (1 IN 4 ADULTS) FIFTY PERCENT ATTEMPT TO
QUIT ANNUALLYFIFTY PERCENT ATTEMPT TO QUIT ANNUALLY ONLY 42% OF
M.I. SMOKERS RECEIVED SMOKING CESSATION INTERVENTIONS AT HOSPITAL
DISCHARGE (NRMI II)ONLY 42% OF M.I. SMOKERS RECEIVED SMOKING
CESSATION INTERVENTIONS AT HOSPITAL DISCHARGE (NRMI II) ONLY 21% OF
SMOKERS RECEIVED COUNSELING @ CLINIC VISITS (1995)ONLY 21% OF
SMOKERS RECEIVED COUNSELING @ CLINIC VISITS (1995) TREATMENT IS
MOST OFTEN OFFERED TO THOSE WITH TOBACCO-RELATED DISEASESTREATMENT
IS MOST OFTEN OFFERED TO THOSE WITH TOBACCO-RELATED DISEASES
DIRECT/INDIRECT MEDICAL COSTS APPROACH $130 BILLION
ANNUALLYDIRECT/INDIRECT MEDICAL COSTS APPROACH $130 BILLION
ANNUALLY
Slide 9
U.S. Deaths Attributable to Cigarette Smoking, 1994, Centers
for Disease Control and Prevention
Slide 10
CIGARETTE SMOKING MORTALITY ONE IN EVERY FIVE DEATHS FROM
CARDIOVASCULAR DISEASE IN THE UNITEDSTATES IS SMOKING-RELATEDONE IN
EVERY FIVE DEATHS FROM CARDIOVASCULAR DISEASE IN THE UNITEDSTATES
IS SMOKING-RELATED ON AVERAGE, SMOKERS DIE SEVEN YEARS EARLIER THAN
NONSMOKERS.ON AVERAGE, SMOKERS DIE SEVEN YEARS EARLIER THAN
NONSMOKERS. 430,700 DEATHS OCCUR ANNUALLY FROM CIGARETTE SMOKING
WITH 75% BEING DUE TO CANCERS AND HEART DISEASE.430,700 DEATHS
OCCUR ANNUALLY FROM CIGARETTE SMOKING WITH 75% BEING DUE TO CANCERS
AND HEART DISEASE. DEATHS FROM LUNG CANCER AMONG WOMENHAVE
INCREASED 400%. IN 1994, 64,300 WOMEN DIED FROM LUNG CANCER AND
44,300 DIED FROM BREAST CANCER.DEATHS FROM LUNG CANCER AMONG
WOMENHAVE INCREASED 400%. IN 1994, 64,300 WOMEN DIED FROM LUNG
CANCER AND 44,300 DIED FROM BREAST CANCER. ONE IN EVERY FIVE DEATHS
FROM CARDIOVASCULAR DISEASE IN THE UNITEDSTATES IS
SMOKING-RELATEDONE IN EVERY FIVE DEATHS FROM CARDIOVASCULAR DISEASE
IN THE UNITEDSTATES IS SMOKING-RELATED ON AVERAGE, SMOKERS DIE
SEVEN YEARS EARLIER THAN NONSMOKERS.ON AVERAGE, SMOKERS DIE SEVEN
YEARS EARLIER THAN NONSMOKERS. 430,700 DEATHS OCCUR ANNUALLY FROM
CIGARETTE SMOKING WITH 75% BEING DUE TO CANCERS AND HEART
DISEASE.430,700 DEATHS OCCUR ANNUALLY FROM CIGARETTE SMOKING WITH
75% BEING DUE TO CANCERS AND HEART DISEASE. DEATHS FROM LUNG CANCER
AMONG WOMENHAVE INCREASED 400%. IN 1994, 64,300 WOMEN DIED FROM
LUNG CANCER AND 44,300 DIED FROM BREAST CANCER.DEATHS FROM LUNG
CANCER AMONG WOMENHAVE INCREASED 400%. IN 1994, 64,300 WOMEN DIED
FROM LUNG CANCER AND 44,300 DIED FROM BREAST CANCER. MORBIDITY AND
MORTALITY WEEKLY REPORT, 1997 AMERICAN CANCER SOCIETY, ATLANTA
GEORGIA, 1996.
Slide 11
Cigarette Smoking as a CHD Risk Factor In PDAY study of
autopsies performed on 1443 men and women aged 15-34 years, smoking
was associated with excess of fatty streaks and raised lesions in
the abdominal aorta. Mechanism of injury from cigarette smoking may
come from injury to endothelium, and acute effects ma include
alterations in clotting, platelet adhesion, and coronary
vasoconstriction due to nicotine. Relative risk of CHD death from
MRFIT study 2.1 for 1-25 cigarettes/day rising to 2.9 for >25
cigarettes/day Acute MI and sudden death strongly associated with
cigarette smoking. Cigarette smoking has additive effect to CHD
risk above lipids, obesity, diabetes, and hypertension
Environmental Tobacco Smoke and CHD 35,000-40,000 deaths
annually from acute MI are associated with environmental tobacco
exposure, significantly more than due to lung cancer. Recent meta
analysis of passive smoking incorporating home-based and workplace
studies (1699 cases) showed relative risk of 1.49 (1.29-1.72)
Sidestream smoke released into the environment may be more toxic
and nonsmokers who are exposed regularly develop various
physiologic changes and are more sensitive than regular smokers.
Lower HDL-C and platelet abnormalities, higher CO levels and lower
exercise tolerance are noted.
Slide 14
Trends in Cigarette Smoking: High School Youth (Everett et
al)
Slide 15
Percent of High School Students Who Reported Cigarette Smoking,
1995, CDC
Slide 16
Percent of Adults Who Reported Cigarette Smoking, 1996,
CDC
Slide 17
Prevention and Intervention Strategies in Youth School-based
prevention programs Social environment / influences Community-based
prevention programs May enhance effects of school-based programs
State and federal prevention initiatives Anti-tobacco media
campaigns Restrictions on tobacco advertising Restrictions on
tobacco availability to minors Restrictions on smoking in public
places including schools Increased taxation
Slide 18
Adult Cessation Strategies Contingency contracting (wards for
abstinence) Social support (from clinician, group, family, friends)
Relaxation techniques (progressive relaxation, deep breathing)
Stimulus control and cue extinction (restricting where smoking
takes place) Coping skills Reduced smoking and nicotine fading
(gradual reduction) Multicomponent treatment programs Hypnosis
Acupuncture Self-help (written materials, videos, tapes, hotlines,
helplines) Computer-tailored messages
Slide 19
Time-to-Benefit of Smoking Cessation After Last Cigarette
Within 20 minutes: BP decreases; body temperature, pulse rate
returns to normal Within 24 hours: Risk of MI decreases Within 1
year: Excess risk for CHD is half that of a person who smokes At 5
years: Stroke risk is reduced to that of someone who has never
smoked Within 15 years: CHD risk is the same as a person who has
never smoked American Lung Association.
www.lungusa.org/tobacco/quit_ben.html
Slide 20
Counseling: 5 As Ask: Systematically identify all tobacco-users
at every visit Advise: Strongly urge all smokers to quit Attempt:
Identify smokers willing to try and quit Assist: Aid the patient in
quitting Arrange: Schedule follow-up contact
Slide 21
Estimated cessation rate (%) Efficacy of various behavioural
support approaches USDHHS. Treating Tobacco use and dependence. A
clinical practice guideline. Rockville, MD AHQR 2000.
% Abstinent at 4 months Tailored vs. generic behavioural
support material Self-help materials tailored for the needs of
individual smokers are more effective than standard materials
Strecher VJ. Patient Educ Couns. 1999; 36: 107-117. Strecher VJ, et
al. Journal of Family Practice. 1994; 39(3): 262270.
Slide 24
Pharmacologic Treatment Options TREATMENTPOTENTIAL RISKS
Nicotine patchSkin rashes and irritation Nicotine polacrilex
(nicotine gum) Mouth soreness, hiccups, dyspepsia, jaw ache
Nicotine nasal sprayNose and eye irritation, usually disappears
within 1 week Nicotine inhalerMay cause mouth or throat irritation
Zyban (bupropion hydrochloride) Slight risk of seizure,
contraindicated in those with eating or seizure disorders
Slide 25
Nicotine Replacement Therapy Potent psychoactive drug that
induces euphoria Effects are related to blood concentration and the
rate of increase in concentration Safe in patients with
cardiovascular disease Should be used as part of smoking cessation
therapy; however, many individuals may quit without it
Slide 26
Smoking and Nicotine Other toxins in tobacco smoke, not
nicotine, are responsible for majority of adverse health effects
>4000 different chemicals Tar, carbon monoxide, irritants, and
oxidant gases >40 carcinogens The main adverse effect of
nicotine from tobacco is addiction, which sustains tobacco use
Nicotine dependence leads to continued exposure to toxins in
tobacco smoke Smith et al. Food Chem Toxicol. 1997;35:110730.
Hoffman and Hoffman. J Toxicol Environ Health. 1997;50:30764.
Benowitz NL. Nicotine Safety and Toxicity. New York: Oxford
University Press, 1998.
Slide 27
Nicotine Replacement Therapy (NRT) Goal: Attenuate symptoms
related to nicotine withdrawal Dysphoric or depressed mood Insomnia
Irritability, frustration, or anger Anxiety Difficulty
concentrating Restlessness Decreased heart rate Increased appetite
or weight gain
Slide 28
NRT: Treatment Options Forms of NRT: Gum, Patch, Inhaler,
Lozenge, Nasal spray, Sublingual tablet All forms of NRT appear to
be similarly effective NRT choice may be based on susceptibility to
side effects, patient preference, and availability Little research
on combinations of different types of NRT Limited evidence that
adding another form of NRT to the nicotine patch increases the
success rate
Slide 29
Minutes Increase in nicotine concentration ( ng/ml ) Cigarette
Gum 4 mg Gum 2 mg Inhaler Nasal spray Patch 5 10 15 20 25 30 0 2 4
6 8 10 12 14 Plasma nicotine concentrations for smoking and NRT
Balfour DJ and Fagerstrm KO. Pharmacol Ther. 1996;72:51-81.
Slide 30
NRT: Benefit of Behavioral Support West R, McNeill A and Raw M.
Thorax. 2000;55:987-999. Silagy C, et al. Nicotine replacement
therapy for smoking cessation. Cochrane Database Syst Rev. 2002; 1.
Limited Support Intensive Support
Slide 31
Safety of NRT NRT is safe in most individuals with
cardiovascular disease, even with concomitant smoking There is a
negligible risk of cancer compared to the risk from continued
smoking Although it is a potential fetal teratogen, the benefits
outweigh the risks of smoking during pregnancy There is a low risk
of abuse
Slide 32
Buproprion (Zyban) Sustained release form of the antidepressant
Acts by enhancing CNS noradrenergic and dopaminergic function Start
1 week before smoking cessation date 150 mg QD x 3d, then 150 mg
BID x 60d Higher doses and longer duration with greater side
effects and no clear benefit
Slide 33
Buproprion (Zyban) vs. NRT Jorenby DE et al. N Engl J Med. 1999
Mar 4;340(9):685-91
Reduced risk cigarettes Includes low tar and light cigarettes,
and novel products that deliver nicotine with minimal tobacco
combustion Low tar cigarettes have not be shown to substantially
reduce health hazards of smoking but do provide sufficient nicotine
to sustain addiction Some novel products may deliver fewer or lower
levels of toxins but some deliver more carbon monoxide. Smoking
cessation medications are most likely safer than any reduced risk
cigarette
Slide 36
Smokeless tobacco Snuff or chewing tobacco has been suggested
as a potential aid to harm reduction or smoking cessation Such
products known to cause oral cancer Smokeless tobacco is addictive
and not recommended for smoking cessation
Slide 37
CLINICAL PRACTICE GUIDELINE TREATING TOBACCO USE AND DEPENDENCE
6,000 ARTICLES (1975-99) INCORPORATING 50 META-ANALYSES6,000
ARTICLES (1975-99) INCORPORATING 50 META-ANALYSES REF: JAMA 2000;
283: 3244-3254REF: JAMA 2000; 283: 3244-3254 AVAILABLE ON
HTTP://WWW.AHQR.GOVAVAILABLE ON HTTP://WWW.AHQR.GOV 6,000 ARTICLES
(1975-99) INCORPORATING 50 META-ANALYSES6,000 ARTICLES (1975-99)
INCORPORATING 50 META-ANALYSES REF: JAMA 2000; 283: 3244-3254REF:
JAMA 2000; 283: 3244-3254 AVAILABLE ON HTTP://WWW.AHQR.GOVAVAILABLE
ON HTTP://WWW.AHQR.GOV U.S. DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Slide 38
THE CLINICAL PRACTICE GUIDELINE ON SMOKING WHATS NEW? TREATMENT
OF TOBACCO MUST BE CONSIDERED A CHRONIC DISEASETREATMENT OF TOBACCO
MUST BE CONSIDERED A CHRONIC DISEASE ALL CLINICIANS SHOULD OFFER AT
LEAST A 3 MIN COUNSELING INTERACTION AT EVERY VISITALL CLINICIANS
SHOULD OFFER AT LEAST A 3 MIN COUNSELING INTERACTION AT EVERY VISIT
ALL SMOKERS WILLING TO QUIT SHOULD BE OFFERED PHARMACOTHERAPY
(EXCEPTIONS: PREGNANT/ BREAST - FEEDING WOMEN, ADOLESCENTS, THOSE
WITH MEDICAL CONTRAINDICATIONS, OR < 10 CIGS/DAY)ALL SMOKERS
WILLING TO QUIT SHOULD BE OFFERED PHARMACOTHERAPY (EXCEPTIONS:
PREGNANT/ BREAST - FEEDING WOMEN, ADOLESCENTS, THOSE WITH MEDICAL
CONTRAINDICATIONS, OR < 10 CIGS/DAY) TREATMENT OF TOBACCO MUST
BE CONSIDERED A CHRONIC DISEASETREATMENT OF TOBACCO MUST BE
CONSIDERED A CHRONIC DISEASE ALL CLINICIANS SHOULD OFFER AT LEAST A
3 MIN COUNSELING INTERACTION AT EVERY VISITALL CLINICIANS SHOULD
OFFER AT LEAST A 3 MIN COUNSELING INTERACTION AT EVERY VISIT ALL
SMOKERS WILLING TO QUIT SHOULD BE OFFERED PHARMACOTHERAPY
(EXCEPTIONS: PREGNANT/ BREAST - FEEDING WOMEN, ADOLESCENTS, THOSE
WITH MEDICAL CONTRAINDICATIONS, OR < 10 CIGS/DAY)ALL SMOKERS
WILLING TO QUIT SHOULD BE OFFERED PHARMACOTHERAPY (EXCEPTIONS:
PREGNANT/ BREAST - FEEDING WOMEN, ADOLESCENTS, THOSE WITH MEDICAL
CONTRAINDICATIONS, OR < 10 CIGS/DAY)
Slide 39
THE CLINICAL PRACTICE GUIDELINE ON SMOKING WHATS NEW?
CLINICIANS AND HEALTH CARE DELIVERY SYSTEMS MUST IDENTIFY,
DOCUMENT, AND TREAT EVERY TOBACCO USERCLINICIANS AND HEALTH CARE
DELIVERY SYSTEMS MUST IDENTIFY, DOCUMENT, AND TREAT EVERY TOBACCO
USER INSURERS AND PURCHASERS SHOULD REIMBURSE:INSURERS AND
PURCHASERS SHOULD REIMBURSE: a. COUNSELING/PHARMACOTHERAPY FOR
PATIENTS PATIENTS b. CLINICIANS WHO PROVIDE TOBACCO DEPENDENCE
TREATMENT DEPENDENCE TREATMENT CLINICIANS AND HEALTH CARE DELIVERY
SYSTEMS MUST IDENTIFY, DOCUMENT, AND TREAT EVERY TOBACCO
USERCLINICIANS AND HEALTH CARE DELIVERY SYSTEMS MUST IDENTIFY,
DOCUMENT, AND TREAT EVERY TOBACCO USER INSURERS AND PURCHASERS
SHOULD REIMBURSE:INSURERS AND PURCHASERS SHOULD REIMBURSE: a.
COUNSELING/PHARMACOTHERAPY FOR PATIENTS PATIENTS b. CLINICIANS WHO
PROVIDE TOBACCO DEPENDENCE TREATMENT DEPENDENCE TREATMENT
Slide 40
PERFORMANCE MEASURES FOR SMOKING CESSATION: HOW DO THEY DIFFER?
AMA -(1) ALL CHRONIC STABLE CORONARY ARTERY DISEASE PTS IDENTIFIED
AS SMOKERS DURING THE REPORTING YEAR (2) ALL CHRONIC STABLE
CORONARY ARTERY DISEASE PTS WHO RECEIVE TOBACCO CESSATION
INTERVENTION IN THE REPORTING YEAR HCFA - ALL AMI PTS. SMOKING
WITHIN ONE YEAR PRIOR TO ADMISSION WHO RECEIVE SMOKING CESSATION
ADVICE OR COUNSELING DURING HOSPITALIZATION AMA -(1) ALL CHRONIC
STABLE CORONARY ARTERY DISEASE PTS IDENTIFIED AS SMOKERS DURING THE
REPORTING YEAR (2) ALL CHRONIC STABLE CORONARY ARTERY DISEASE PTS
WHO RECEIVE TOBACCO CESSATION INTERVENTION IN THE REPORTING YEAR
HCFA - ALL AMI PTS. SMOKING WITHIN ONE YEAR PRIOR TO ADMISSION WHO
RECEIVE SMOKING CESSATION ADVICE OR COUNSELING DURING
HOSPITALIZATION
Slide 41
PERFORMANCE MEASURES FOR SMOKING CESSATION: HOW DO THEY DIFFER?
NCQA - BY SURVEY ALL CURRENT/RECENT QUITTERS THAT HAD ONE OR MORE
VISITS INDICATING THEY RECEIVED ADVICE TO QUIT FROM AN MCO
PRACTITIONER JCAHO - ALL AMI PATIENTS SMOKING WITHIN THE YEAR PRIOR
TO ADMISSION WHO RECEIVE SMOKING CESSATION ADVICE OR COUNSELING
DURING HOSPITALIZATION NCQA - BY SURVEY ALL CURRENT/RECENT QUITTERS
THAT HAD ONE OR MORE VISITS INDICATING THEY RECEIVED ADVICE TO QUIT
FROM AN MCO PRACTITIONER JCAHO - ALL AMI PATIENTS SMOKING WITHIN
THE YEAR PRIOR TO ADMISSION WHO RECEIVE SMOKING CESSATION ADVICE OR
COUNSELING DURING HOSPITALIZATION
Slide 42
POINT OF ACCESS: THE USE OF HOSPITALS FOR SMOKING CESSATION
30-40 MILLION PEOPLE HOSPITALIZED ANNUALLY 20-30% OF HOSPITALIZED
PATIENTS SMOKE MOST SMOKERS HAVE HAD TO QUIT GREATER MOTIVATION TO
QUIT OPPORTUNITY FOR COUNSELING 30-40 MILLION PEOPLE HOSPITALIZED
ANNUALLY 20-30% OF HOSPITALIZED PATIENTS SMOKE MOST SMOKERS HAVE
HAD TO QUIT GREATER MOTIVATION TO QUIT OPPORTUNITY FOR
COUNSELING
Slide 43
GENERAL INTERVENTION METHODS INHOSPITAL RN/MD COUNSELINGRN/MD
COUNSELING AUDIOVISUAL MATERIALSAUDIOVISUAL MATERIALS SELF-HELP
PAMPHLETSSELF-HELP PAMPHLETSPOSTHOSPITAL RN INITIATED PHONE
CALLS:RN INITIATED PHONE CALLS: WEEKLY X 2-3 WEEKS MONTHLY X 4-6
MONTHS NICOTINE REPLACEMENT THERAPYNICOTINE REPLACEMENT THERAPY 1-2
FACE-TO-FACE VISITS AS NEEDED1-2 FACE-TO-FACE VISITS AS
NEEDEDINHOSPITAL RN/MD COUNSELINGRN/MD COUNSELING AUDIOVISUAL
MATERIALSAUDIOVISUAL MATERIALS SELF-HELP PAMPHLETSSELF-HELP
PAMPHLETSPOSTHOSPITAL RN INITIATED PHONE CALLS:RN INITIATED PHONE
CALLS: WEEKLY X 2-3 WEEKS MONTHLY X 4-6 MONTHS NICOTINE REPLACEMENT
THERAPYNICOTINE REPLACEMENT THERAPY 1-2 FACE-TO-FACE VISITS AS
NEEDED1-2 FACE-TO-FACE VISITS AS NEEDED
Slide 44
DISSEMINATION OF STAYING FREE SMOKING CESSATION PROGRAM PRIMARY
AIM TO DETERMINE EFFECTIVENESS OF INITIAL IMPLEMENTATION INTO
SEVERAL HOSPITALS IN SAN FRANCISCO BAY AREATO DETERMINE
EFFECTIVENESS OF INITIAL IMPLEMENTATION INTO SEVERAL HOSPITALS IN
SAN FRANCISCO BAY AREA SECONDARY AIM TO IMVESTIGATE FACTORS THAT
PREDICT SUSTAINABILITY OF STAYING FREETO IMVESTIGATE FACTORS THAT
PREDICT SUSTAINABILITY OF STAYING FREE PRIMARY AIM TO DETERMINE
EFFECTIVENESS OF INITIAL IMPLEMENTATION INTO SEVERAL HOSPITALS IN
SAN FRANCISCO BAY AREATO DETERMINE EFFECTIVENESS OF INITIAL
IMPLEMENTATION INTO SEVERAL HOSPITALS IN SAN FRANCISCO BAY AREA
SECONDARY AIM TO IMVESTIGATE FACTORS THAT PREDICT SUSTAINABILITY OF
STAYING FREETO IMVESTIGATE FACTORS THAT PREDICT SUSTAINABILITY OF
STAYING FREE
Slide 45
STAYING FREE INTERVENTION WHAT PATIENTS RECEIVE: A STRONG
PHYSICIAN MESSAGE ABOUT THE HAZARDS OF SMOKING A 17 PAGE WORKBOOK
ON QUITTING SMOKING A 16 MINUTE VIDEOTAPE SHOWN AT THE BEDSIDE
ABOUT HOW TO REMAIN AN EX-SMOKER A RELAXATION AUDIOTAPE WHAT
PATIENTS RECEIVE: A STRONG PHYSICIAN MESSAGE ABOUT THE HAZARDS OF
SMOKING A 17 PAGE WORKBOOK ON QUITTING SMOKING A 16 MINUTE
VIDEOTAPE SHOWN AT THE BEDSIDE ABOUT HOW TO REMAIN AN EX-SMOKER A
RELAXATION AUDIOTAPE
Slide 46
STAYING FREE INTERVENTION WHAT PATIENTS RECEIVE: A COUNSELING
SESSION AT THE BEDSIDE BY A HEALTH CARE PROFESSIONAL
PHARMACOLOGICAL THERAPY AS NEEDED FOLLOW-UP PHONE CALLS FROM
HOSPITAL STAFF AND/OR PUBLIC HEALTH (1 TO 4) OUTPATIENT REFERRALS
TO PUBLIC HEALTH PROGRAMS AND OTHER LOCAL RESOURCES WHAT PATIENTS
RECEIVE: A COUNSELING SESSION AT THE BEDSIDE BY A HEALTH CARE
PROFESSIONAL PHARMACOLOGICAL THERAPY AS NEEDED FOLLOW-UP PHONE
CALLS FROM HOSPITAL STAFF AND/OR PUBLIC HEALTH (1 TO 4) OUTPATIENT
REFERRALS TO PUBLIC HEALTH PROGRAMS AND OTHER LOCAL RESOURCES
Slide 47
STANDARD PROGRAM IMPLEMENTATION STAYING FREE HOSPITAL ADVISORY
BOARD MULTIDISCIPLINARY TEAM COMPRISED OF PHYSICIANS,
PSYCHOLOGISTS, NURSING STAFF, SOCIAL WORKERS, RESPIRATORY
THERAPISTS AND OTHERS PHYSICIAN ORIENTATIONPHYSICIAN ORIENTATION
HOT PINK STAYING FREE STICKERS PLACED ON PATIENT CHARTS TO CUE
PHYSICIANS TO DELIVER STRONG MESSAGE PHYSICIAN INFORMATION POCKET
CARDS GRAND ROUNDS OR MONTHLY STAFF MEETING PRESENTATIONSREGARDING
PHYSICIANS KEY ROLE IN SMOKING CESSATION GRAND ROUNDS OR MONTHLY
STAFF MEETING PRESENTATIONS REGARDING PHYSICIANS KEY ROLE IN
SMOKING CESSATION STAYING FREE HOSPITAL ADVISORY BOARD
MULTIDISCIPLINARY TEAM COMPRISED OF PHYSICIANS, PSYCHOLOGISTS,
NURSING STAFF, SOCIAL WORKERS, RESPIRATORY THERAPISTS AND OTHERS
PHYSICIAN ORIENTATIONPHYSICIAN ORIENTATION HOT PINK STAYING FREE
STICKERS PLACED ON PATIENT CHARTS TO CUE PHYSICIANS TO DELIVER
STRONG MESSAGE PHYSICIAN INFORMATION POCKET CARDS GRAND ROUNDS OR
MONTHLY STAFF MEETING PRESENTATIONSREGARDING PHYSICIANS KEY ROLE IN
SMOKING CESSATION GRAND ROUNDS OR MONTHLY STAFF MEETING
PRESENTATIONS REGARDING PHYSICIANS KEY ROLE IN SMOKING
CESSATION
Slide 48
STANDARD PROGRAM IMPLEMENTATION PATIENT IDENTIFICATION
COMPUTERIZED ADMISSIONS FORMS OR PAPER ADMISSIONS SLIPS NURSING
HISTORIES SELF REFERRAL TRIGGERED BY PUBLICITY MATERIALS (E.G.,
POSTERS) IDENTIFICATION QUESTIONS HAVE YOU SMOKED ANY TOBACCO
PRODUCTS IN THE PAST 30 DAYS? ARE YOU WILLING TO MAKE AN ATTEMPT TO
QUIT SMOKING DURING THIS HOSPITALIZATION? REFERRALREFERRAL
PHYSICIANS, CASE MANAGERS, NURSING AND UNIT STAFF DEDICATED STAYING
FREE TELEPHONE LINE REFERRAL SLIPS PATIENT IDENTIFICATION
COMPUTERIZED ADMISSIONS FORMS OR PAPER ADMISSIONS SLIPS NURSING
HISTORIES SELF REFERRAL TRIGGERED BY PUBLICITY MATERIALS (E.G.,
POSTERS) IDENTIFICATION QUESTIONS HAVE YOU SMOKED ANY TOBACCO
PRODUCTS IN THE PAST 30 DAYS? ARE YOU WILLING TO MAKE AN ATTEMPT TO
QUIT SMOKING DURING THIS HOSPITALIZATION? REFERRALREFERRAL
PHYSICIANS, CASE MANAGERS, NURSING AND UNIT STAFF DEDICATED STAYING
FREE TELEPHONE LINE REFERRAL SLIPS
Slide 49
PATIENT EDUCATION NURSING AND/OR INTERVENTION STAFF PROVIDE
PATIENT WORKBOOK, VIDEOTAPE AND RELAXATION AUDIOTAPE FOLLOW-UP
TELEPHONE CONTACTFOLLOW-UP TELEPHONE CONTACT 1 TO 4 TIMES POST
DISCHARGE PATIENT EDUCATION NURSING AND/OR INTERVENTION STAFF
PROVIDE PATIENT WORKBOOK, VIDEOTAPE AND RELAXATION AUDIOTAPE
FOLLOW-UP TELEPHONE CONTACTFOLLOW-UP TELEPHONE CONTACT 1 TO 4 TIMES
POST DISCHARGE STANDARD PROGRAM IMPLEMENTATION
Slide 50
SPECIAL FEATURES:SPECIAL FEATURES: INTERVENTION PROVIDED BY
PSYCHOLOGISTS, PSYCHOLOGY INTERNS AND QUALITY ASSURANCE NURSE USE
OF CLOSED CIRCUIT TV TO SHOW VIDEO USE OF COMPUTERIZED STAYING FREE
TEMPLATES TO DOCUMENT INTERVENTION IN PATIENTS ELECTRONIC MEDICAL
RECORDS STAYING FREE GROUP E-MAIL CREATED TO DISSEMINATE
INFORMATION/UPDATES TO TEAM ASK ME ABOUT STAYING FREE ID TAGS FOR
STAFF SPECIAL FEATURES:SPECIAL FEATURES: INTERVENTION PROVIDED BY
PSYCHOLOGISTS, PSYCHOLOGY INTERNS AND QUALITY ASSURANCE NURSE USE
OF CLOSED CIRCUIT TV TO SHOW VIDEO USE OF COMPUTERIZED STAYING FREE
TEMPLATES TO DOCUMENT INTERVENTION IN PATIENTS ELECTRONIC MEDICAL
RECORDS STAYING FREE GROUP E-MAIL CREATED TO DISSEMINATE
INFORMATION/UPDATES TO TEAM ASK ME ABOUT STAYING FREE ID TAGS FOR
STAFF MODEL I: A VA HOSPITAL PALO ALTO HEALTH CARE SYSTEM
Slide 51
SPECIAL FEATURES:SPECIAL FEATURES: INTERVENTION PROVIDED BY
PHYSICIANS FOLLOW-UP PHONE CALLS PROVIDED BY SANTA CLARA COUNTY
PUBLIC HEALTH TOBACCO PREVENTION AND EDUCATION PROGRAM SPANISH AND
VIETNAMESE LANGUAGE VERSIONS OF STAYING FREE CERTIFICATES OF
ACHIEVEMENT FOR PATIENTS SPECIAL FEATURES:SPECIAL FEATURES:
INTERVENTION PROVIDED BY PHYSICIANS FOLLOW-UP PHONE CALLS PROVIDED
BY SANTA CLARA COUNTY PUBLIC HEALTH TOBACCO PREVENTION AND
EDUCATION PROGRAM SPANISH AND VIETNAMESE LANGUAGE VERSIONS OF
STAYING FREE CERTIFICATES OF ACHIEVEMENT FOR PATIENTS MODEL II: A
COUNTY HOSPITAL SANTA CLARA VALLEY MEDICAL CENTER
Slide 52
SPECIAL FEATURES:SPECIAL FEATURES: MILLS-PENINSULA HEALTH
SERVICES INTERVENTION PROVIDED BY CARDIAC REHABILITATION AND A
DIVERSE TEAM OF VOLUNTEERS (NURSING STUDENT, FORMER CARDIAC
REHABILITATION PATIENTS, MENDED HEARTS VOLUNTEERS, RETIRED
COUNSELORS) DEDICATED STAYING FREE PHONE LINE COMMUNITY HOSPITAL OF
LOS GATOS INTERVENTION PROVIDED BY STAFF CHAPLAIN COMPUTERIZED
IDENTIFICATION OF ALL SMOKERS AT ADMISSION SPECIAL FEATURES:SPECIAL
FEATURES: MILLS-PENINSULA HEALTH SERVICES INTERVENTION PROVIDED BY
CARDIAC REHABILITATION AND A DIVERSE TEAM OF VOLUNTEERS (NURSING
STUDENT, FORMER CARDIAC REHABILITATION PATIENTS, MENDED HEARTS
VOLUNTEERS, RETIRED COUNSELORS) DEDICATED STAYING FREE PHONE LINE
COMMUNITY HOSPITAL OF LOS GATOS INTERVENTION PROVIDED BY STAFF
CHAPLAIN COMPUTERIZED IDENTIFICATION OF ALL SMOKERS AT ADMISSION
MODEL III: COMMUNITY HOSPITALS
Slide 53
SPECIAL FEATURES:SPECIAL FEATURES: PARTNERSHIP WITH COMMUNITY
AND PATIENT RELATIONS PROGRAM INTERVENTION PROVIDED BY SMOKING
CESSATION ADVISORS, (HEALTH PROFESSIONAL VOLUNTEERS AND MEDICAL
SCHOOL TRACK UNDERGRADUATES) SPECIAL FEATURES:SPECIAL FEATURES:
PARTNERSHIP WITH COMMUNITY AND PATIENT RELATIONS PROGRAM
INTERVENTION PROVIDED BY SMOKING CESSATION ADVISORS, (HEALTH
PROFESSIONAL VOLUNTEERS AND MEDICAL SCHOOL TRACK UNDERGRADUATES)
MODEL IV: A UNIVERSITY TEACHING HOSPITAL STANFORD UNIVERSITY
HOSPITAL
Slide 54
MAKING HOSPITAL-WIDE SYSTEM LEVEL CHANGES THAT SUCCEED STEP 1:
DETERMINE PERCENTAGE OF ALL SMOKERS ENTERING A HOSPITAL WHO SMOKED
IN PAST 30 DAYS ADMISSION SHEETSADMISSION SHEETS FACE TO FACE
CONTACT (2-4 WEEKS)FACE TO FACE CONTACT (2-4 WEEKS) STEP 1:
DETERMINE PERCENTAGE OF ALL SMOKERS ENTERING A HOSPITAL WHO SMOKED
IN PAST 30 DAYS ADMISSION SHEETSADMISSION SHEETS FACE TO FACE
CONTACT (2-4 WEEKS)FACE TO FACE CONTACT (2-4 WEEKS)
Slide 55
MAKING HOSPITAL-WIDE SYSTEM LEVEL CHANGES THAT SUCCEED STEP 2:
ACTIVELY SCREEN ALL SMOKERS UTILIZE COMPUTERIZED ADMISSION
FORMUTILIZE COMPUTERIZED ADMISSION FORM INCORPORATE INTO NURSING
HISTORIESINCORPORATE INTO NURSING HISTORIES INTEGRATE AS PART OF
STANDING CCU/CSU ADMISSION ORDERSINTEGRATE AS PART OF STANDING
CCU/CSU ADMISSION ORDERS INCORPORATE AS A VITAL SIGNINCORPORATE AS
A VITAL SIGN USE PATIENT STICKERSUSE PATIENT STICKERS STEP 2:
ACTIVELY SCREEN ALL SMOKERS UTILIZE COMPUTERIZED ADMISSION
FORMUTILIZE COMPUTERIZED ADMISSION FORM INCORPORATE INTO NURSING
HISTORIESINCORPORATE INTO NURSING HISTORIES INTEGRATE AS PART OF
STANDING CCU/CSU ADMISSION ORDERSINTEGRATE AS PART OF STANDING
CCU/CSU ADMISSION ORDERS INCORPORATE AS A VITAL SIGNINCORPORATE AS
A VITAL SIGN USE PATIENT STICKERSUSE PATIENT STICKERS
Slide 56
MAKING HOSPITAL-WIDE SYSTEM LEVEL CHANGES THAT SUCCEED STEP 3:
EXPECT ALL HEALTH CARE PROFESSIONALS TO INTERVENE ASK ABOUT SMOKING
STATUS APPROPRIATELYASK ABOUT SMOKING STATUS APPROPRIATELY OFFER
MOTIVATIONAL INTERVIEWOFFER MOTIVATIONAL INTERVIEW DOCUMENT,
DOCUMENT, DOCUMENT (TRACKING FORM, PROGRESS NOTES)DOCUMENT,
DOCUMENT, DOCUMENT (TRACKING FORM, PROGRESS NOTES) STEP 3: EXPECT
ALL HEALTH CARE PROFESSIONALS TO INTERVENE ASK ABOUT SMOKING STATUS
APPROPRIATELYASK ABOUT SMOKING STATUS APPROPRIATELY OFFER
MOTIVATIONAL INTERVIEWOFFER MOTIVATIONAL INTERVIEW DOCUMENT,
DOCUMENT, DOCUMENT (TRACKING FORM, PROGRESS NOTES)DOCUMENT,
DOCUMENT, DOCUMENT (TRACKING FORM, PROGRESS NOTES)
Slide 57
MAKING HOSPITAL-WIDE SYSTEM LEVEL CHANGES THAT SUCCEED STEP 4:
TRAIN ALL MDs TO RESPOND ASK ABOUT SMOKING STATUS APPROPRIATELYASK
ABOUT SMOKING STATUS APPROPRIATELY OFFER STRONG, CREDIBLE MESSAGE
ABOUT QUITTINGOFFER STRONG, CREDIBLE MESSAGE ABOUT QUITTING
DETERMINE NEED FOR PHARMACOLOGICAL THERAPYDETERMINE NEED FOR
PHARMACOLOGICAL THERAPY DOCUMENT, DOCUMENT, DOCUMENT (MEDICAL
RECORD, TRACKING FORM)DOCUMENT, DOCUMENT, DOCUMENT (MEDICAL RECORD,
TRACKING FORM) STEP 4: TRAIN ALL MDs TO RESPOND ASK ABOUT SMOKING
STATUS APPROPRIATELYASK ABOUT SMOKING STATUS APPROPRIATELY OFFER
STRONG, CREDIBLE MESSAGE ABOUT QUITTINGOFFER STRONG, CREDIBLE
MESSAGE ABOUT QUITTING DETERMINE NEED FOR PHARMACOLOGICAL
THERAPYDETERMINE NEED FOR PHARMACOLOGICAL THERAPY DOCUMENT,
DOCUMENT, DOCUMENT (MEDICAL RECORD, TRACKING FORM)DOCUMENT,
DOCUMENT, DOCUMENT (MEDICAL RECORD, TRACKING FORM)
Slide 58
MAKING HOSPITAL-WIDE SYSTEM LEVEL CHANGES THAT SUCCEED STEP 5:
CONSIDER A SYSTEM TO OFFER SELF-HELP MATERIALS AND BEHAVIORAL
COUNSELING STANDARDIZE PATIENT EDUCATION MATERIALSSTANDARDIZE
PATIENT EDUCATION MATERIALS UTILIZE CLOSED-CIRCUIT TELEVISION FOR
VIDEOTAPESUTILIZE CLOSED-CIRCUIT TELEVISION FOR VIDEOTAPES
DETERMINE WHO CAN BE TRAINED TO PROVIDE BEHAVIORAL COUNSELING (ie.
VOLUNTEERS, CANDIDATE MEDICAL STUDENTS, CHAPLAINS, NURSES,
PSYCHOLOGISTS)DETERMINE WHO CAN BE TRAINED TO PROVIDE BEHAVIORAL
COUNSELING (ie. VOLUNTEERS, CANDIDATE MEDICAL STUDENTS, CHAPLAINS,
NURSES, PSYCHOLOGISTS) PROVIDE A LIST OF COMMUNITY RESOURCESPROVIDE
A LIST OF COMMUNITY RESOURCES STEP 5: CONSIDER A SYSTEM TO OFFER
SELF-HELP MATERIALS AND BEHAVIORAL COUNSELING STANDARDIZE PATIENT
EDUCATION MATERIALSSTANDARDIZE PATIENT EDUCATION MATERIALS UTILIZE
CLOSED-CIRCUIT TELEVISION FOR VIDEOTAPESUTILIZE CLOSED-CIRCUIT
TELEVISION FOR VIDEOTAPES DETERMINE WHO CAN BE TRAINED TO PROVIDE
BEHAVIORAL COUNSELING (ie. VOLUNTEERS, CANDIDATE MEDICAL STUDENTS,
CHAPLAINS, NURSES, PSYCHOLOGISTS)DETERMINE WHO CAN BE TRAINED TO
PROVIDE BEHAVIORAL COUNSELING (ie. VOLUNTEERS, CANDIDATE MEDICAL
STUDENTS, CHAPLAINS, NURSES, PSYCHOLOGISTS) PROVIDE A LIST OF
COMMUNITY RESOURCESPROVIDE A LIST OF COMMUNITY RESOURCES
Slide 59
MAKING HOSPITAL-WIDE SYSTEM LEVEL CHANGES THAT SUCCEED STEP 6:
DETERMINE A MECHANISM FOR FOLLOW-UP USE SMOKING INTERVENTIONISTS TO
UNDERTAKE PATIENT FOLLOW-UPUSE SMOKING INTERVENTIONISTS TO
UNDERTAKE PATIENT FOLLOW-UP OFFER TELEPHONE CONTACT BY HEALTH CARE
PROFESSIONALS ALREADY MAKING CALLSOFFER TELEPHONE CONTACT BY HEALTH
CARE PROFESSIONALS ALREADY MAKING CALLS INTEGRATE CALLS WITHIN
PUBLIC HEALTH DEPT.INTEGRATE CALLS WITHIN PUBLIC HEALTH DEPT. USE
CENTRALIZED TELEPHONE SYSTEM FOR ALL SMOKERS WITHIN COMMUNITYUSE
CENTRALIZED TELEPHONE SYSTEM FOR ALL SMOKERS WITHIN COMMUNITY
DOCUMENT, DOCUMENT, DOCUMENTDOCUMENT, DOCUMENT, DOCUMENT STEP 6:
DETERMINE A MECHANISM FOR FOLLOW-UP USE SMOKING INTERVENTIONISTS TO
UNDERTAKE PATIENT FOLLOW-UPUSE SMOKING INTERVENTIONISTS TO
UNDERTAKE PATIENT FOLLOW-UP OFFER TELEPHONE CONTACT BY HEALTH CARE
PROFESSIONALS ALREADY MAKING CALLSOFFER TELEPHONE CONTACT BY HEALTH
CARE PROFESSIONALS ALREADY MAKING CALLS INTEGRATE CALLS WITHIN
PUBLIC HEALTH DEPT.INTEGRATE CALLS WITHIN PUBLIC HEALTH DEPT. USE
CENTRALIZED TELEPHONE SYSTEM FOR ALL SMOKERS WITHIN COMMUNITYUSE
CENTRALIZED TELEPHONE SYSTEM FOR ALL SMOKERS WITHIN COMMUNITY
DOCUMENT, DOCUMENT, DOCUMENTDOCUMENT, DOCUMENT, DOCUMENT
Slide 60
Clinicians Guide, Agency for Health Care Policy and
Research
Slide 61
Quit Smoking Action Plan, American Lung Association