Steven A. Schroeder, MDProfessor of Medicine

University of California San FranciscoSan Francisco, California

Get Your Patients with HIV/AIDS to Stop Smoking Before it Kills Them

FORMATTED: 11/03/2015

New Orleans, Louisiana: December 15-17, 2015

Slide 2 of 56

Tobacco’s Deadly Toll

540,000 deaths in the U.S. each year* 4.8 million deaths world wide each year

--Current trends show >8 million deaths annually by 2030 42,000 deaths in the U.S. due to second-hand smoke

exposure 14 million in U.S. with smoking related diseases (60% with COPD) 42.1 million smokers in U.S. (76.9% daily smokers, averaging

14.2 cigarettes/day, 2013)

* Carter et al, NEJM, Feb 12, 2015

Slide 3 of 56

1955

1957

1959

1961

1963

1965

1967

1969

1971

1973

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2009

2011

2013

0

10

20

30

40

50

60

TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2013

20.5%

15.3%

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; 1965–2013 NHIS. Estimates since 1992 include some-day smoking.

68.8% want to quit

17.8% of adults are

current smokers

Male

Female

Per

cen

t

Slide 4 of 56Smoking Prevalence and Average Number of Cigarettes Smoked per

Day per Current Smoker 1965-2010

Source: Schroeder, JAMA 2012; 308:1586; *CDC/NCHS, National Health Interview Survey, 1997-March 2015, Sample Adult Core

Per

cent

/Num

ber

of C

igar

ette

s S

mok

ed D

aily

*January-March 2015: 15.3% prevalence!

Slide 5 of 56

Health Consequences of Smoking

U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General, 2010.

Cancers– Acute myeloid leukemia – Bladder and kidney– Cervical– Colon, liver, pancreas– Esophageal– Gastric– Laryngeal– Lung– Oral cavity and pharyngeal– Prostate (↓survival)

Pulmonary diseases– Acute (e.g., pneumonia)– Chronic (e.g., COPD)– Tuberculosis

Cardiovascular diseases– Abdominal aortic aneurysm– Coronary heart disease– Cerebro-vascular disease– Peripheral arterial disease– Type 2 diabetes mellitus

Reproductive effects– Reduced fertility in women– Poor pregnancy outcomes

(ectopic pregnancy, congenital anomalies, low birth weight, preterm delivery)

– Infant mortality; childhood obesity

Other effects: cataract; osteoporosis; Crohn’s; periodontitis; poor surgical outcomes; Alzheimer’s; rheumatoid arthritis; less sleep

Slide 6 of 56

Causal Associations with Second-hand Smoke

Developmental– Low birthweight– Sudden infant death

syndrome (SIDS)– Pre-term delivery-- Childhood depression

Respiratory– Asthma induction and

exacerbation– Eye and nasal irritation– Bronchitis, pneumonia, otitis

media, bruxism in children– Decreased hearing in teens

Carcinogenic– Lung cancer– Nasal sinus cancer– Breast cancer? (younger, premenopausal women)

Cardiovascular– Heart disease mortality

– Acute and chronic coronary heart disease morbidity

– Altered vascular properties

USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General.

There is no safe level of

second-hand

smoke.

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Smoking and Behavioral Health: The Heavy Burden

240,000 annual deaths from smoking occur among patients with Chronic Mental Illness (CMI) and/or substance abuse

This population consumes 40% of all cigarettes sold in the United States-- higher prevalence-- smoke more-- more likely to smoke down to the butt

People with CMI die earlier than others, and smoking is a large contributor to that early mortality

Greater risk for nicotine withdrawal Social isolation from smoking compounds the social stigma

Slide 8 of 56

Smoking Imperils the HIV/AIDS Population

LGBT persons and those with substance use disorders have higher smoking rates

HIV/AIDS patients have higher smoking rates HIV patients who smoke have greater odds of

heart disease, cancer, CVA, and HIV-related infections than HIV patients who do not smoke

Slide 9 of 56

Nicotine enters brain

Stimulation of nicotine receptors

Dopamine release

Dopamine Reward PathwayPrefrontal

cortex

Nucleus accumbens

Ventral tegmental

area

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Nicotine Addiction Tobacco users maintain a minimum serum

nicotine concentration in order to– Prevent withdrawal symptoms– Maintain pleasure/arousal– Modulate mood

Users self-titrate nicotine intake by– Smoking more frequently– Smoking more intensely– Obstructing vents on low-nicotine brand

cigarettes

Slide 11 of 56

Tools for Smoking Cessation

5As (Ask, Advise, Assess, Assist, Arrange) AAR (Ask, Advise, Refer) Quitlines NRT and other medications Counseling and behavioral change strategies Peer-to-peer intervention

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Treatment

Persons with HIV, mental illnesses, and substance use disorders benefit from same interventions as general population

Combination of counseling and pharmacotherapy should be used whenever possible

Duration of treatment might be longer View failed quit attempt as a practice, not failure

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Cognitive Strategies for Cessation

Review commitment to quit, focus on downsides of tobacco use

Reframe the way a patient thinks about smoking Distractive thinking Positive self-talks, “pep talks” Relaxation through imagery Mental rehearsal, visualization

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Behavioral Strategies for Cessation (Avoiding Stimuli that Trigger

Smoking)

Stress – Anticipate future challenges– Develop substitutes for tobacco

Alcohol – Limit or abstain during early stages of

quitting Other tobacco users

– Stay away– Ask for cooperation from family and

friends

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Behavioral Strategies for Cessation (Part 2)

Oral gratification needs – Use substitutes: water, sugar-free chewing

gum or hard candies Automatic smoking routines

– Anticipate routines and develop alternative plans, e.g., with morning coffee

Weight gain after cessation – Anticipate; use gum or bupropion; exercise

Cravings – Distractive thinking; change activities

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PHARMACOTHERAPY

Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.

Medications significantly improve success rates. * Includes pregnant women, smokeless tobacco users, light smokers, and adolescents.

“Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations* for which there is insufficient evidence of effectiveness.”

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Pharmacologic Methods: First-line Therapies*

Three general classes of FDA-approved medications for smoking cessation: Nicotine replacement therapy (NRT)

-- nicotine gum, patch, lozenge, nasal spray, inhaler Partial nicotine receptor agonist

-- varenicline--? cytisine in the future

Psychotropics-- sustained-release bupropion

* Counseling plus meds better than either alone

Currently, no medications have an FDA indication for use in spit tobacco cessation.

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Caveats About Cessation Literature Smoking should be thought of as a chronic condition,

yet drug treatment often short (12 weeks) in contrast to methadone maintenance

Great spectrum of severity and addiction; treatment should be tailored accordingly

Volunteers for studies likely to be more motivated to quit

Placebo and drug groups tend to have more intensive counseling than found in real practice world; and counseling is not a monolithic black box

Most drug trials exclude patients with mental illness

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LONG-TERM (6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS

0

5

10

15

20

25

30

Nicotine gum Nicotinepatch

Nicotinelozenge

Nicotinenasal spray

Nicotineinhaler

Bupropion Varenicline

Active drugPlacebo

Data adapted from Cahill et al. (2012). Cochrane Database Syst Rev; Stead et al. (2012). Cochrane Database Syst Rev; Hughes et al. (2007). Cochrane Database Syst Rev

Per

cen

t q

uit

16.3 15.9

10.0 9.8

18.9

8.4

23.9

11.8

17.1

9.1

18.9

10.612.0

28.0

Slide 20 of 56

Quitlines and Behavioral Health

Do quitlines work for people with MI and/or SUD? Yes

Are they able to meet the demand? They are underused

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Tips for Your Office

Referral forms to the quitline (1-800-QUITNOW) Carbon monoxide breathalyzer (cost about $500

plus disposal mouthpieces) One key question to ask: “When do you have your

first cigarette of the day?” Approach smoking as a chronic illness, just like

HIV/AIDS in 2015

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Contact SCLC for Technical Assistance

Visit us online http://smokingcessationleadership.ucsf.edu

– CME/CE webinars– Fact sheets, toolkits, publications– Training resources and presentations– E-newsletter and listserv– Online ordering for 1-800-QUIT NOW cards

Call us toll-free 1-877-509-3786

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The Electronic Cigarette*

Aerosolizes nicotine in propylene glycol solvent; e-cig products in evolution

Cartridges contain about 20 mg nicotine Safety unproven, but >cigarette smoke Probably deliver < nicotine than promised Unclear if help smokers quit Not approved by FDA My advice: avoid unless patient insists

* Cobb & Abrams. NEJM July 21, 2011; Fiore, Schroeder, Baker, NEJM Jan 23, 2014

Slide 24 of 56

Cigarette and E-Cigarette Use among High School Students, 2000-2014

Source: Youth Risk Behavior Survey