Setting the Stage: Tobacco s Impact on Smokers, Employers, and Florida

Transcription

1 Setting the Stage: Tobacco s Impact on Smokers, Employers, and Florida Thomas H. Brandon, Ph.D. H. Lee Moffitt Cancer Center & Research Institute Florida Tobacco Cessation Summit October 14, 2010

2 Moffitt Cancer Center National Cancer Institute Designated Comprehensive Cancer Center Dedicated to the prevention and cure of cancer Employees; 662 Active Volunteers 732 Research Faculty & Staff 7,742 admissions annually; 289,364 outpatient visits annually $77.2 Million in research grants in 2010 Built with state funds from tobacco taxes.

3 T.R.I.P. Primary mission: To conduct research on tobacco dependence and its prevention and treatment. Secondary missions: To provide tobacco control services and consultation to region and nation. To train the next generation of tobacco researchers.

4 T.R.I.P. Largest research group in Florida dedicated solely to studying tobacco dependence. Team of >50: 6 Ph.D. scientists 6 doctoral students 15 research support staff ~25 undergraduate research assistants

5 Range of Research Basic human laboratory research Brain activity (ERP) associated with nicotine withdrawal Genetic markers of tobacco dependence Translational Applying contemporary models of animal learning to smoking cessation Clinical Trials Self-help smoking cessation booklets Web intervention for college students

6 Current Cigarette Use among Adults (2008) Percent Smoking US UT CA NY FL GA SC AL WV Source: MMWR, 11/13/09

7 Smoking in Florida Never Smokers 55.3% Former Smokers 27.6% Current Smokers 17.1% Smoke Every Day 12.8% Smoke Some Days 4.3% Source: BRFFS, 2009

8 Groups With High Prevalence (2008) Percent Smoking US Native Americans No HS Diploma GED Below Poverty Source: MMWR, 11/13/09

9 Smoking by Age - Florida Percent Smoking Florida Source: BRFFS, 2009

10 Smoking by Education - Florida Percent Smoking Florida < HS HS or GED Some Post-HS College Grad Source: BRFFS, 2009

11 Smoking by Income - Florida Percent Smoking Florida < $15K $15-25K $25-35K $35-50K $50-75K $75K+ Source: BRFFS, 2009

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13 Health Burden of Tobacco Approximately 438,000 Annual U.S. Deaths Attributable to Cigarette Smoking ( Data) Stroke 17,400 Other Cancers 34,700 Other Diagnoses 84,600 Lung Cancer 123,800 Source: MMWR 2005: 54, Chronic Lung Disease 90,600 Coronary Heart Disease 86,800

14 Annual Premature Avoidable Deaths 0! 100! 200! 300! 400! 500,000! AIDS" Alcohol" Motor Vehicle" Fires" Homicide" Illicit Drugs" Suicide" Smoking"

15 Florida Fatalities Average fatalities per 10 years: Shark attacks 2-3 Alligator attacks 10 Lightening strikes 90 Murders 10,000 Tobacco use 300,000

16 Why do People (Adolescents) Start Smoking? Each day, 3000 U.S. children begin smoking. Why? Adult role models Peer influence Rebellion Stress Beliefs about the positive effects of smoking Delayed health risks not relevant to teens Tobacco advertising enhances all of these effects.

17 Why Do People Continue Smoking? Nearly 50 million Americans have quit smoking. Yet, nearly another 50 million continue to smoke. Why do they continue, despite all the health warnings and social prohibitions?? Addiction. (Tobacco Dependence)

18 Tobacco Addiction

19 Nicotine is Addictive Tolerance Withdrawal Compulsive Use

20 Nicotine Withdrawal Symptoms (DSM-IV): dysphoric or depressed mood insomnia irritability, frustration, or anger anxiety difficulty concentrating restlessness decreased heart rate increased appetite or weight gain Craving for tobacco Time Course: highly variable, but often begins on Day 1 most symptoms peak Days 2-4 largely resolved by Days 7-10

21 Nicotine and the Brain Nicotine enters the bloodstream from the lungs upon smoking, then rapidly (~10 secs) reaches the brain. Nicotine acts as a Central Nervous System stimulant, leading to autonomic arousal ( HR, BP, resp). Nicotine has paradoxical effects ( Nesbitt s Paradox"). Nicotine has diverse neurochemical effects: Dopamine Serotonin Glutamate GABA Acetylcholine, cortisol Endogenous opioids (b-endorphin)

22 Smokers Have Increased Nicotinic Receptors in Prefrontal Cortex

23 Heritability for Tobacco Use Twin Design: MZ vs. DZ twins Hughes (1986): 3 cohorts - long-term smoker : 53% Sullivan & Kendler (1999): 16 cohorts - smoking initiation: 56% - nicotine dependence: 67% Li, Cheng, Ma, & Swan (2003): 17 cohorts - smoking initiation males: 37% females: 55% - smoking persistence males: 59% females: 46%

24 Environmental Factors Social groups Availability of tobacco products Cost (price of cigarettes) Opportunity (smoke-free policies)

25 Psychological Factors Expectations (beliefs) Improves mood Controls weight Makes one social Regulating Negative Mood Increasing attention/concentration. Mental Illness

26 The tobacco industry exploits all the known addictive factors

27 How addicting is tobacco? Surveys of addicts. Addiction Index Historical Examples (Germany, Sultan Murad IV, )

28 Smoking Cessation Treatments Pharmacotherapies double the quitting rate: Nicotine Replacement (patch, gum, inhaler, nasal spray, lozenge) Bupropion SR (Zyban ) Varenicline (Chantix ) So does behavioral counseling: Coping skills, relapse prevention. Best outcomes are with combination of pharmacotherapy and behavioral counseling.

29 Smoking Relapse To cease smoking is the easiest thing I ever did I ought to know; I've done it a thousand times.

30 Rate of Relapse % Abstinent Heroin Smoking Alcohol Months (Hunt et al., 1971)

31 Economic Burden of Tobacco Use: Annual Costs National Florida Direct Health Care Expenditures Workplace Productivity Losses $116.4 billion $7.2 billion $67.5 billion $4.4 billion Premature Death $117.1 billion $7.9 billion Total Cost to Economy $301.0 billion $19.6 billion Actual Cost of Pack of Cigarettes $18.05 $16.43 American Lung Association (2010) Smoking Cessation: The Economic Benefits

32 Cost-Effectiveness of Smoking Interventions Per Quitter Per Life- Year Saved Nicotine patch with minimal counseling $4,745 $3,248 Individual intensive counseling w/o NRT $3,595 $2,461 Intensive group counseling with patch $2,310 $1,581 Cromwell et al. (1997) [add 43% for 2010 dollars]

33 Cost-Effectiveness (QALY) Intensive counseling w/ patch $1,581 1 HIV blood donor screening $14,000 Flashing lights at rail crossings $42,000 Annual mammography $190,000 Neonatal intensive care $270,000 Universal precautions for HIV $890,000 Ejection system for B-58 bomber $1,200,000 Seat belts in school buses $2,800, Cromwell et al. (1997) 2 Tengs et al. (1995) Treatment of tobacco dependence called the gold standard of healthcare cost-effectiveness (Eddy, 1992).

34 USPHS Recommendations Recommendation: The tobacco dependence treatments shown to be effective in this guideline (both counseling and medication) are highly cost-effective relative to other reimbursed treatments and should be provided to all smokers. (Strength of Evidence = A)

35 USPHS Recommendations Recommendation: Providing tobacco dependence treatments (both medication and counseling) as a paid or covered benefit by health insurance plans has been shown to increase the proportion of smokers who use cessation treatment, attempt to quit, and successfully quit. Therefore, treatments shown to be effective in the Guideline should be included as covered services in public and private health benefit plans. (Strength of Evidence = A)

36 Coverage Makes a Difference Percentage No Coverage Coverage 0 Intervention Rate Quit Attempts Abstinence Rate Source: USPHS, Treating Tobacco Use and Dependence, 2008

37 Smoking Treatment Coverage: A Sound Investment Estimates for Manufacturing Work Force of 10,000 Employees (1995) Source: Warner et al., J Occup Env Med, 1996.

38 Smoking Treatment Coverage: Wisconsin Experience ( ) WI Dept of Employee Trust Funds Results A Sound Investment State employees, dependents, retirees Plan offered 3 months of pharmacotherapy 6-7% used smoking cessation benefit annually (17% over three years) Average cost per user: $ Average cost per enrollee: $1.60 Cost per member per month: $0.13 Source: Burns et al., Am J. Prev. Med., 2007

39 Smoking Treatment Coverage: A Sound Investment Group Health Cooperative (Seattle, ) Economic Analysis mg bupropion (Zyban ) plus phone counseling Results 5-year Return on Investment (ROI): % Internal Rate of Return (IRR) per year: 24-31% Conclusion: Smoking cessation is profitable for employers. Source: Javitz et al., Value in Health, 2004

40 Summary Tobacco dependence is a chronic, relapsing, and often fatal disorder. Economic costs are enormous. Significant costs to employers. Tobacco cessation treatments are effective and cost-effective. Providing coverage for treatment is both ethical and profitable for employers.

41 Disclosures Recent Funding Sources National Cancer Institute National Institute on Drug Abuse National Institute of Alcohol Abuse and Alcoholism American Cancer Society Prevent Cancer Foundation March of Dimes State of Florida Relevant Consulting Pfizer sanofi-aventis