5,000. China 35.6 (66.9/4.2) Number of cigarettes 4,000. Japan 33.1 (52.8/13.4) 3,000. Philippines 32.4 (53.8/11.0) 2,000 1,000

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1 TRAINING OVERVIEW Rx for CHANGE Clinician-Assisted Tobacco Cessation Epidemiology of Tobacco Use module Forms of Tobacco module Nicotine Pharmacology & Principles of Addiction module Drug Interactions with Smoking module Assisting Patients with Quitting module Hands-on workshop Aids for Cessation module Tobacco trigger tapes Case scenarios EPIDEMIOLOGY of TOBACCO USE CIGARETTE SMOKING is the chief, single, avoidable cause of death in our society and the most important public health issue of our time. C. Everett Koop, M.D., former U.S. Surgeon General USA 2.9 (23.9/18.1) Canada 2. (27./23.) Brazil 33.8 (38.2/29.3) WORLDWIDE ADULT TOBACCO USE PREVALENCE (Men/Women) UK 26. (27./26.) Guinea 1.7 (9./43.8) France 34. (38.6/3.3) Namibia. (6./3.) Sweden 19. (19./19.) Yugoslavia 47. (2./42.) Iran 1.3 (27.2/3.4) India 16. (29.4/2.) Australia 19. (21.1/18.) Russian Federation 36. (63.2/9.7) China 3.6 (66.9/4.2) Japan 33.1 (2.8/13.4) Philippines 32.4 (3.8/11.) South Africa 26. (42./11.) New Zealand 2. (2./2.) Mackay & Erickson. (22). The Tobacco Atlas. World Health Organization. Number of cigarettes TRENDS in ADULT CIGARETTE CONSUMPTION U.S., 19 2 Annual adult per capita cigarette consumption and major smoking and health events, 4, 3, 2, 1, U.S. entry into WW I Great Depression End of WW II 1964 Surgeon General s Report Marketing of filtered cigarettes First modern reports linking smoking and cancer Nonsmokers rights movement begins Broadcast ad ban Federal cigarette tax doubles Master Settlement Agreement; California first state to enact ban on smoking in bars Cigarette price drop Centers for Disease Control and Prevention. (1999). MMWR 48: Per-capita updates from U.S. Department of Agriculture, provided by the American Cancer Society. 2 states have > $1 pack tax Copyright The Regents of the University of California, University of Southern 1

2 Pounds of tobacco per capita ADULT PER-CAPITA CONSUMPTION of TOBACCO, Snuff Chewing tobacco Cigars Pipe/roll your own Cigarettes All forms of tobacco are harmful Adapted from NCI Smoking and Tobacco Control Monograph 8, 1997, p. 13. Data from U.S. Department of Agriculture. Reprinted with permission. Thun et al. 22. Oncogene 21: Percent TRENDS in ADULT SMOKING, by SEX U.S., 19 2 Trends in cigarette current smoking among persons aged 18 or older Male Female 23.9% 18.1% % want to quit 2.9% of adults are current smokers Graph provided by the Centers for Disease Control and Prevention. 19 Current Population Survey; NHIS. Estimates since 1992 include some-day smoking. California 1.2% STATE-SPECIFIC PREVALENCE of SMOKING among ADULTS, 2 Illinois 19.9% Kentucky 28.7% PREVALENCE of ADULT SMOKING, by RACE/ETHNICITY U.S., 2 32.% American Indian/Alaska Native* 21.9% White* Nevada 23.1% Utah 11.% Texas 2.% Indiana 27.3% New York 2.% Florida 21.6% 21.% Black* 16.2% Hispanic 13.3% Asian* % 1% 2% 3% 4% % * non-hispanic. Centers for Disease Control and Prevention. (26). MMWR : Centers for Disease Control and Prevention. (26). MMWR : PREVALENCE of ADULT SMOKING, by EDUCATION U.S., 2 TRENDS in TEEN SMOKING, by ETHNICITY U.S., % No high school diploma 43.2% GED diploma 24.6% High school graduate 22.% Some college 1.7% Undergraduate degree Percent Trends in cigarette smoking among 12th graders: 3-day prevalence of use White Hispanic Black % 1% 2% 3% 4% % 7.1% Graduate degree Centers for Disease Control and Prevention. (26). MMWR : Institute for Social Research, University of Michigan, Monitoring the Future Project Copyright The Regents of the University of California, University of Southern 2

3 PUBLIC HEALTH versus BIG TOBACCO The biggest opponent to tobacco control efforts is the tobacco industry itself. The TOBACCO INDUSTRY For decades, the tobacco industry has publicly denied the addictive nature of nicotine and the negative health effects of tobacco. April 14, 1994: Seven top executives of major tobacco companies state, under oath, that they believe nicotine is not addictive. Tobacco industry documents suggest otherwise Documents available at In the U.S., for every $1 spent on tobacco prevention, the tobacco industry spends $28 to market its products. The cigarette is a heavily engineered product. Designed and marketed to maximize bioavailability of nicotine and addictive potential Profits over people An EFFECTIVE MARKETING STRATEGY: LIGHT CIGARETTES The difference between Marlboro and Marlboro Lights TOBACCO INDUSTRY ADVERTISING $1.1 billion spent in the U.S. in % increase over 22 figures 3.% increase over 21 figures an extra row of ventilation holes Billions of dollars spent Image courtesy of Mayo Clinic Nicotine Dependence Center - Research Program / Dr. Richard D. Hurt The Marlboro and Marlboro Lights logos are registered trademarks of Philip Morris USA. Federal Trade Commission. (2). Cigarette Report for 23. ANNUAL U.S. DEATHS ATTRIBUTABLE to SMOKING, ANNUAL SMOKING-ATTRIBUTABLE ECONOMIC COSTS U.S., Cardiovascular diseases Lung cancer Respiratory diseases Second-hand smoke* Cancers other than lung Other 137, ,836 11,44 38,112 34,693 1,828 Percentage of all smokingattributable deaths* 32% 28% 23% 9% 8% <1% Medical expenditures (1998) Annual lost productivity costs ( ) Ambulatory care, $27.2 billion Men, $.4 billion Hospital care, $17.1 billion Prescription drugs, $6.4 billion Societal costs: $7.18 per pack Nursing home, $19.4 billion Other care, $.4 billion Women, $26. billion TOTAL: 437,92 deaths annually * In 2, it was estimated that nearly, persons died due to second-hand smoke exposure. Centers for Disease Control and Prevention. (2). MMWR 4: Billions of dollars Centers for Disease Control and Prevention. (22). MMWR 1:3 33. Copyright The Regents of the University of California, University of Southern 3

4 COMPOUNDS in TOBACCO SMOKE An estimated 4,8 compounds in tobacco smoke, including 11 proven human carcinogens Gases Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde Particles Nicotine Nitrosamines Lead Cadmium Polonium-21 Nicotine does NOT cause the ill health effects of tobacco. 24 REPORT of the SURGEON GENERAL: HEALTH CONSEQUENCES OF SMOKING FOUR MAJOR CONCLUSIONS: Smoking harms nearly every organ of the body, causing many diseases and reducing the health of smokers in general. Quitting smoking has immediate as well as long-term benefits, reducing risks for diseases caused by smoking and improving health in general. Smoking cigarettes with lower machine-measured yields of tar and nicotine provides no clear benefit to health. The list of diseases caused by smoking has been expanded. U.S. Department of Health and Human Services. (24). The Health Consequences of Smoking: A Report of the Surgeon General. HEALTH CONSEQUENCES of SMOKING 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) Cardiovascular diseases Abdominal aortic aneurysm Coronary heart disease Cerebrovascular disease Peripheral arterial disease Reproductive effects Reduced fertility in women Poor pregnancy outcomes (e.g., low birth weight, preterm delivery) Infant mortality Other effects: cataract, osteoporosis, periodontitis, poor surgical outcomes U.S. Department of Health and Human Services. (24). The Health Consequences of Smoking: A Report of the Surgeon General. 26 REPORT of the SURGEON GENERAL: INVOLUNTARY EXPOSURE to TOBACCO SMOKE Second-hand smoke causes premature death and disease There is no in nonsmokers (children and adults) safe level of Children: second-hand Increased risk for sudden infant death syndrome smoke. (SIDS), acute respiratory infections, ear problems, and more severe asthma Respiratory symptoms and slowed lung growth if parents smoke Adults: Immediate adverse effects on cardiovascular system Increased risk for coronary heart disease and lung cancer Millions of Americans are exposed to smoke in their homes/workplaces Indoor spaces: eliminating smoking fully protects nonsmokers Separating smoking areas, cleaning the air, and ventilation are ineffective USDHHS. (26). The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General. SMOKE-FREE WORKPLACE LAWS Smoke-free offices, restaurants, and bars: California, Colorado, Connecticut, Delaware, Hawaii, Maine, Massachusetts, New Jersey, New York, Rhode Island, Vermont, Washington Smoke-free offices and restaurants: Arkansas, District of Columbia (bars in 27), Florida, Georgia, Idaho, Louisiana, Montana (bars in 29), Nevada, North Dakota, Utah (bars in 29) Smoke-free offices: Maryland, South Dakota Data current as of November 9, 26. Circulation improves, walking becomes easier QUITTING: HEALTH BENEFITS Lung function increases up to 3% Excess risk of CHD decreases to half that of a continuing smoker Lung cancer death rate drops to half that of a continuing smoker Risk of cancer of mouth, throat, esophagus, bladder, kidney, pancreas decrease Time Since Quit Date 2 weeks to 3 months 1 year 1 years 1 to 9 months years after 1 years Lung cilia regain normal function Ability to clear lungs of mucus increases Coughing, fatigue, shortness of breath decrease Risk of stroke is reduced to that of people who have never smoked Risk of CHD is similar to that of people who have never smoked Copyright The Regents of the University of California, University of Southern 4

5 FEV 1 (% of value at age 2) BENEFICIAL EFFECTS of QUITTING: PULMONARY EFFECTS AT ANY AGE, there are benefits of quitting Disability Death Smoked regularly and susceptible to effects of smoke 7 Age (years) Never smoked or not susceptible to smoke Stopped smoking at 4 (mild COPD) Stopped smoking at 6 (severe COPD) COPD = chronic obstructive pulmonary disease Reduction in cumulative risk of death from lung cancer in men Cumulative risk (%) Age in years Reprinted with permission. Fletcher & Peto. (1977). BMJ 1(677): Reprinted with permission. Peto et al. (2). BMJ 321(727): s of life gained Prospective study of 34,439 male British doctors Mortality was monitored for years (191 21) 1 1 SMOKING CESSATION: REDUCED RISK of DEATH Age at cessation (years) On average, cigarette smokers die approximately 1 years younger than do nonsmokers. Among those who continue smoking, at least half will die due to a tobacco-related disease. Doll et al. (24). BMJ 328(74): Packs per day FINANCIAL IMPACT of SMOKING Buying cigarettes every day for $4.26 per pack Money banked monthly, earning 1.% interest $114,243 $228,486 $342, Hundreds of thousands of dollars lost EPIDEMIOLOGY of TOBACCO USE: SUMMARY About one in five adults are current smokers; smoking prevalence varies by sociodemographic characteristics. Nearly half a million U.S. deaths are attributable to smoking annually. Smoking costs the U.S. $17.7 billion per year. Lifetime financial costs of smoking can exceed $3, for a heavy smoker. At any age, there are benefits to quitting smoking. The biggest opponent to tobacco control efforts is the tobacco industry itself. Copyright The Regents of the University of California, University of Southern

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