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1 t TRAINING OVERVIEW Rx for CHANGE Clinician-Assisted Tobacco Cessation for Surgical Patients Epidemiology of Tobacco Use Benefits e of Qutt Quitting for Surgical gca Patients ate ts Tobacco Dependence and Medications for Quitting Changing Behavior How You Can Help Developed through a collaboration of the American Society for Anesthesiologists and the Rx for Change: Clinician-Assisted Tobacco Cessation program. Funded by the National Cancer Institute and the Robert Wood Johnson Foundation. 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 o per capita Pounds of tobacco ADULT PER-CAPITA CONSUMPTION of TOBACCO, Snuff Chewing tobacco Cigars Pipe/roll your own Cigarettes All forms of tobacco are harmful Year 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., Trends in cigarette current smoking among persons aged 18 or older Male 7% want to quit 2.8% of adults are current smokers Female 23.9% 18.% Year Graph provided by the Centers for Disease Control and Prevention. 19 Current Population Survey; NHIS. Estimates since 1992 include some-day smoking. Copyright The Regents of the University of California and the American Society of Anesthesiologists. All rights reserved. Updated October 28. 1

2 t TRENDS in TEEN SMOKING, by ETHNICITY U.S., PUBLIC HEALTH versus BIG TOBACCO Percent Trends in cigarette smoking among 12th graders: 3-day prevalence of use White Hispanic Black The biggest opponent to tobacco control efforts is the tobacco industry itself. Nationally, the tobacco industry is outspending our state tobacco control funding Year Institute for Social Research, University of Michigan, Monitoring the Future Project For every $1 spent by the states, the tobacco industry spends $18 to market its products. Billions of dollars spent TOBACCO INDUSTRY ADVERTISING $13.11 billion spent in the U.S. in 2 $3.9 million a day 9% increase over 1998 figures 1 1 New marketing restrictions Year Federal Trade Commission. (27). Cigarette Report for 24 and 2. The TOBACCO INDUSTRY For decades, the tobacco industry 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: (video) Tobacco industry documents indicate otherwise Documents available at The cigarette is a heavily engineered product. Designed and marketed to maximize bioavailability of nicotine and addictive potential Profits over people ANNUAL U.S. DEATHS ATTRIBUTABLE to SMOKING, Cardiovascular diseases 137,979 Lung cancer 123,836 Respiratory diseases 11,44 Second-hand smoke* 38,112 Cancers other than lung 34,693 Other 1,828 Percentage of all smokingattributable deaths* 32% 28% 23% 9% 8% <1% 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 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: Nicotine is the addictive component of tobacco products, but it does NOT cause the ill health effects of tobacco use. Copyright The Regents of the University of California and the American Society of Anesthesiologists. All rights reserved. Updated October 28. 2

3 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. Medical expenditures (1998) Annual lost productivity costs ( ) ANNUAL SMOKING-ATTRIBUTABLE ECONOMIC COSTS U.S., 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 Billions of dollars Centers for Disease Control and Prevention. (22). MMWR 1: REPORT of the SURGEON GENERAL: INVOLUNTARY EXPOSURE to TOBACCO SMOKE Second-hand smoke causes premature death and disease in nonsmokers (children and adults) Children: Increased risk for sudden infant death syndrome (SIDS), S), acute respiratory infections, ear problems, and more severe asthma There is no safe level of second-hand smoke. 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. Packs per day FINANCIAL IMPACT of SMOKING Buying cigarettes every day for $4.32 per pack Money banked monthly, earning 4% interest $21,72 $3,41 $3,41 $7,177 $7, Dollars lost, in thousands Years 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): Copyright The Regents of the University of California and the American Society of Anesthesiologists. All rights reserved. Updated October 28. 3

4 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 BENEFITS of QUITTING for SURGICAL PATIENTS WHY SHOULD SURGICAL PROVIDERS ADDRESS TOBACCO USE? TOBACCO CESSATION IMPROVES SURGICAL OUTCOMES Quitting Smoking Improves Surgical Outcomes Surgery May Promote Quitting Smoking Quitting reduces the incidence of: Cardiovascular complications Respiratory complications Wound-related complications SHORT-TERM CARDIOVASCULAR BENEFITS OF SMOKING CESSATION Nicotine Half life, approximately 1 2 hours Decreases in heart rate and systolic blood pressure within 12 hours Carbon monoxide Half life, approximately 4 hours Carboxyhemoglobin level near normal at 12 hours Preoperative abstinence decreases the frequency of intraoperative ischemia* Percent SMOKING CESSATION REDUCES POSTOPERATIVE COMPLICATIONS 6 Control Intervention Any Wound Cardiac Type of Complication 12 orthopedic patient randomized to tobacco intervention or control, 6 8 weeks prior to surgery ~8% of intervention patients were able to quit or reduce smoking *Woehlck et al. (1999). Anesth Analg 89: Møller et al. (22). Lancet 39: Copyright The Regents of the University of California and the American Society of Anesthesiologists. All rights reserved. Updated October 28. 4

5 WHY SHOULD SURGICAL CARE CLINICIANS BOTHER? SURGERY PROMOTES TOBACCO CESSATION Quitting Smoking Improves Surgical Outcomes Surgery May Promote Quitting Smoking Opportunity for providers to intervene Contact with healthcare system Forced abstinence in smoke-free facilities Major medical interventions improve quit rates Occurs even in the absence of tobacco interventions May also improve the effectiveness of tobacco interventions SMOKING CESSATION AFTER SURGERY BARRIERS TO PERIOPERATIVE SMOKING CESSATION at 1 year Percent abstinent a Self-help Outpatient cessation programs Major noncardiac surgery bypass Coronary surgery Lung cancer surgery Quitting just before surgery increases pulmonary complications. Nicotine i replacement therapy is dangerous. Surgical patients are already too stressed. Patients don t want to hear about their smoking they have enough to worry about. RECENT SMOKING CESSATION DOES NOT INCREASE PULMONARY COMPLICATIONS NICOTINE REPLACEMENT THERAPY AND WOUND HEALING Perce ent Continued Smokers Recent Quitters Overall Pneumonia Past Quitters Non-Smokers (n=13) (n=39) (n=184) (n=64) 3 patients for lung cancer resection Recent quitters: >1 week, <2 months Past quitters: >2 months Percent Non-abstinent Abstinent, active patch Abstinent, placebo Infection Dehiscience 48 smokers randomized to continuous smoking or abstinence, with or without nicotine replacement Standardized wounds over a 12-week period Barrera et al. (2). Chest 127: Sorensen et al. (23). Ann Surg 238:1. Copyright The Regents of the University of California and the American Society of Anesthesiologists. All rights reserved. Updated October 28.

6 Perceived Stress PERIOPERATIVE STRESS IN SURGICAL PATIENTS Smokers Non-smokers 141 smokers, 1 nonsmokers for elective surgery Perceived stress measured from before surgery up to one week postoperatively (POD=postop day) Smoking status does not affect changes in perceived stress No evidence for significant cigarette cravings Preop Postop POD1 POD2 POD7 Time Warner et al. (24). Anesthesiology 199: WHAT DO PATIENTS WHO SMOKE EXPECT? Essentially all smokers are aware of general health hazards Most are not aware of how it might affect their surgery and want to know! They want information and options Almost all will not be offended if you discuss their smoking But they do not want a sermon Warner et al., unpublished observations. THE REAL BARRIERS TO INTERVENTION I don t know how. I don t have time. It s not my job. TOBACCO DEPENDENCE: A 2-PART PROBLEM Physiological The addiction to nicotine Tobacco Dependence Treatment Medications for cessation Behavioral The habit of using tobacco Treatment Behavior change program Treatment should address the physiological and the behavioral aspects of dependence. TOBACCO DEPENDENCE and MEDICATIONS for QUITTING WHAT IS ADDICTION? Compulsive drug use, without medical purpose, in the face of negative consequences Alan I. Leshner, Ph.D. Former Director, National Institute on Drug Abuse National Institutes of Health Copyright The Regents of the University of California and the American Society of Anesthesiologists. All rights reserved. Updated October 28. 6

7 NICOTINE DISTRIBUTION Prefrontal cortex DOPAMINE REWARD PATHWAY ine (ng/ml) Plasma nicoti Venous Arterial Minutes after light-up of cigarette Nicotine reaches the brain within 11 seconds. Henningfield et al. (1993). Drug Alcohol Depend 33: Nucleus accumbens Dopamine release Ventral tegmental area Stimulation of nicotine receptors Nicotine enters brain BIOLOGY of NICOTINE ADDICTION: ROLE of DOPAMINE Nicotine stimulates dopamine release Pleasurable feelings Repeat administration Nicotine addiction is not just a bad habit. Discontinuation leads to withdrawal symptoms. Tolerance develops Benowitz. (28). Clin Pharmacol Ther 83: NICOTINE PHARMACODYNAMICS: WITHDRAWAL EFFECTS Irritability/frustration/anger Anxiety Most symptoms manifest Difficulty concentrating within the first 1 2 days, Restlessness/impatience peak within the first week, and subside within Depressed mood/depression 2 4 weeks. Insomnia Impaired performance Increased appetite/weight gain Cravings HANDOUT Hughes. (27). Nicotine Tob Res 9: 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/dipping more frequently Smoking more intensely Obstructing vents on low-nicotine brand cigarettes Benowitz. (28). Clin Pharmacol Ther 83: FDA-APPROVED MEDICATIONS for SMOKING CESSATION Nicotine polacrilex gum (OTC) brand (Nicorette), generic Nicotine lozenge (OTC) brand (Commit), generic Nicotine transdermal patch (OTC, Rx) brand (NicoDerm CQ, OTC), generic (OTC, Rx) Nicotine nasal spray (Rx) brand (Nicotrol NS) Nicotine inhaler (Rx) brand (Nicotrol Inhaler) Bupropion SR (Rx) brand (Zyban), generic Varenicline (Rx) brand (Chantix) OTC = Over the counter These are the only medications that are FDA-approved for smoking cessation. Copyright The Regents of the University of California and the American Society of Anesthesiologists. All rights reserved. Updated October 28. 7

8 PHARMACOTHERAPY 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. * Includes pregnant women, smokeless tobacco users, light smokers, and adolescents. Medications significantly improve success rates. Fiore et al. (28). Treating Tobacco Use and Dependence: 28 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 28. NRT: RATIONALE for USE Reduces physical withdrawal from nicotine Eliminates the immediate, reinforcing effects of nicotine that is rapidly absorbed via tobacco smoke Allows patient to focus on behavioral and psychological aspects of tobacco cessation NRT products approximately doubles quit rates. PLASMA NICOTINE CONCENTRATIONS for NICOTINE-CONTAINING PRODUCTS NICOTINE GUM Plasma nicotine ( mcg/l) 2 Cigarette 2 Moist snuff 1 1 1//19 1/1/19 1 1/2/19 1/3/19 2/9/19 4 2/19/19 2/29/19 6 Time (minutes) Cigarette Moist snuff Nasal spray Inhaler Lozenge (2mg) Gum (2mg) Patch Resin complex of nicotine and polacrilin Sugar-free chewing gum base Contains buffering agents to enhance buccal absorption of nicotine Available: 2 mg, 4 mg; original, cinnamon, fruit, mint (various), and orange flavors NICOTINE LOZENGE TRANSDERMAL NICOTINE PATCH Nicotine polacrilex formulation Delivers ~2% more nicotine than equivalent gum dose Sugar-free mint (various), cappuccino or cherry flavor Contains buffering agents to enhance buccal absorption of nicotine Available: 2 mg, 4 mg Nicotine is well absorbed across the skin Delivery to systemic circulation avoids hepatic first-pass metabolism Plasma nicotine levels are lower and fluctuate less than with smoking Available: Brand or generic; nicotine delivery over 24 hours 21 mg, 14 mg, 7 mg Copyright The Regents of the University of California and the American Society of Anesthesiologists. All rights reserved. Updated October 28. 8

9 NICOTINE NASAL SPRAY Aqueous solution of nicotine in a 1-ml spray bottle Each metered dose actuation delivers mcl spray. mg nicotine ~1 doses/bottle Rapid absorption across nasal mucosa Available: Rx only NICOTINE INHALER Nicotine inhalation system consists of: Mouthpiece Cartridge with porous plug containing 1 mg nicotine and 1 mg menthol Delivers 4 mg nicotine vapor, absorbed across buccal mucosa Available: Rx only BUPROPION SR Nonnicotine cessation aid Oral formulation Sustained-release antidepressant Atypical antidepressant thought to affect levels of various brain neurotransmitters (dopamine, norepinephrine) Clinical effects craving for cigarettes symptoms of nicotine withdrawal VARENICLINE Nonnicotine cessation aid Partial nicotinic receptor agonist Oral formulation Binds with high affinity and selectivity at α 4 β 2 neuronal nicotinic acetylcholine receptors Stimulates low-level agonist activity Competitively inhibits binding of nicotine VARENICLINE: CARDIOVASCULAR EFFECTS? α 4 β 2 nicotinic receptor not known to have non-cns effects No evidence for effects on vascular function More data needed VARENICLINE: WARNING In 28, Pfizer added a warning label advising patients and caregivers: Patients should stop taking varenicline and contact Patients should stop taking varenicline and contact their healthcare provider immediately if agitation, depressed mood, or changes in behavior that are not typical for them are observed, or if the patient develops suicidal ideation or suicidal thoughts. Copyright The Regents of the University of California and the American Society of Anesthesiologists. All rights reserved. Updated October 28. 9

10 uit Percent qu LONG-TERM ( 6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS 11.3 Active drug Placebo Nicotine gum Nicotine patch Nicotine lozenge Nicotine nasal spray Nicotine inhaler Bupropion Varenicline Data adapted from Cahill et al. (28). Cochrane Database Syst Rev; Stead et al. (28). Cochrane Database Syst Rev; Hughes et al. (27). Cochrane Database Syst Rev $/day $8 $7 $6 $ $4 $3 $2 $1 $ COMPARATIVE DAILY COSTS of PHARMACOTHERAPY Average $/pack of cigarettes, $4.32 Gum Lozenge Patch Inhaler Nasal spray Bupropion SR Varenicline Trade $6.8 $.26 $3.89 $.29 $3.72 $7.4 $4.7 Generic $3.28 $3.66 $ $ PHARMACOTHERAPY: USE in PREGNANCY The Clinical Practice Guideline makes no recommendation regarding use of medications in pregnant smokers Insufficient evidence of effectiveness; concerns with safety Category C: varenicline, bupropion SR Category D: prescription formulations of NRT Because of the serious risks of smoking to the pregnant smoker and the fetus, whenever possible pregnant smokers should be offered person-to-person psychosocial interventions that exceed minimal advice to quit. (p. 16) Fiore et al. (28). Treating Tobacco Use and Dependence: 28 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 28. CHANGING BEHAVIOR HOW YOU CAN HELP TOBACCO CESSATION REQUIRES BEHAVIOR CHANGE Fewer than % of people who quit without assistance are successful in quitting for more than a year. Few patients adequately PREPARE and PLAN for their quit attempt. Many patients do not understand the need to change behavior Patients think they can just make themselves quit Behavioral counseling is a key component of treatment for tobacco use and dependence. CHANGING BEHAVIOR (cont d) Often, patients automatically smoke in the following situations: When drinking coffee While driving i in the car When bored While stressed While at a bar with friends After meals During breaks at work While on the telephone While with specific friends or family members who use tobacco Behavioral counseling helps patients learn to cope with these difficult situations without having a cigarette. Copyright The Regents of the University of California and the American Society of Anesthesiologists. All rights reserved. Updated October 28. 1

11 CLINICIANS CAN MAKE a DIFFERENCE The NUMBER of CLINICIANS CAN MAKE a DIFFERENCE, too With help from a clinician, the odds of quitting approximately doubles. ence at s Estimated abstine + months n = 29 studies No clinician Compared to patients who receive no assistance from a clinician, patients who receive assistance are times as likely to quit successfully for or more months. Self-help material 1.7 Nonphysician clinician Type of Clinician 2.2 Physician clinician Fiore et al. (28). Treating Tobacco Use and Dependence: 28 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 28. e rate Estimated abstinence at + months n = 37 studies 1. Compared to smokers who receive assistance from no clinicians, smokers who receive assistance from two or more clinicians are times as likely to quit successfully for or more months. 1.8 (1.,2.2) 2. (1.9,3.4) 2.4 (2.1,3.4) None One Two Three or more Number of Clinician Types Fiore et al. (28). Treating Tobacco Use and Dependence: 28 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 28. WHAT SHOULD WE DO FOR SURGICAL PATIENTS? WHAT ARE TOBACCO QUITLINES? ASK ADVISE REFER Patient receives assistance, with follow-up counseling arranged, from other resources such as the tobacco quitline about tobacco USE tobacco users to QUIT to other resources ASSIST ARRANGE Tobacco cessation counseling, provided at no cost via telephone to all Americans Staffed by trained specialists Up to 4 6 personalized sessions (varies by state) Some state quitlines offer nicotine replacement therapy at no cost Up to 3% success rate for patients who complete sessions Most health-care providers, and most patients, are not familiar with tobacco quitlines. ASK EVERY PATIENT ABOUT TOBACCO USE Ask even if you already know the answer Reinforces the message that tobacco use is clinically significant, and quitting is important ADVISE ALL PATIENTS WHO SMOKE TO QUIT: Talking Points Why quit for surgery? Quit for as long as possible before and after surgery Day of surgery is particularly important Advise patient to fast from food and cigarettes Benefits of quitting to wound healing, heart and lungs Great opportunity to quit for good Many people don t have cravings Need to be smoke free in the hospital anyway Copyright The Regents of the University of California and the American Society of Anesthesiologists. All rights reserved. Updated October

12 REFER smokers to quitlines or other resources What are quitlines? talking points Quitlines are free Talk with a specialist, not a recording Free stop smoking medications may be available Can call anytime, even after surgery Can help you stay off cigarettes even if you have already quit Am. Society of Anesthesiologists: QUIT CARD Can also use proactive fax referral 1-8-QUIT-NOW Amer. Society of Anesthesiologists: PATIENT BROCHURE OTHER RESOURCES FOR YOUR PATIENTS Tobacco treatment specialists Available in many practice settings Often hospital-based Websites Insurers e.g., Blue Cross/Shield, BluePrint for Health program OTHER WEB RESOURCES FOR PROVIDERS General portal for information ASA-sponsored site providing information and resources for surgical patients and providers Training materials for clinicians CMS REIMBURSEMENT FOR TOBACCO INTERVENTIONS Who is covered? Patients who use tobacco and have a disease or adverse health effect found by the U.S. Surgeon General to be linked to tobacco use CPT codes 9946: Smoking and tobacco-use cessation counseling visit; intermediate, > 3 minutes up to 1 minutes 9947: Smoking and tobacco-use cessation visit; intensive, > 1 minutes Copyright The Regents of the University of California and the American Society of Anesthesiologists. All rights reserved. Updated October

13 CMS REIMBURSEMENT FOR TOBACCO INTERVENTIONS Cessation counseling attempt occurs when a qualified physician or other Medicare-recognized practitioner determines that a beneficiary meets the eligibility requirements above and initiates treatment with a cessation counseling attempt Two attempts (of up to 4 sessions) allowed every 12 months No credentialing requirements as of yet A COMPREHENSIVE APPROACH Every surgical patient has at least five points of contact when undergoing elective surgery Initial surgical visit (scheduling) Admission to facility Preop visit by anesthesia provider Discharge from facility Post-op surgical visit Each provides an opportunity to provide reinforcing messages if the surgical team can work together WHY SHOULD CLINICIANS ADDRESS TOBACCO? Tobacco users expect to be encouraged to quit by health professionals. Screening for tobacco use and providing tobacco cessation counseling are positively associated with patient satisfaction (Barzilai et al., 21). HELPING PATIENTS QUIT IS a CLINICIAN S RESPONSIBILITY TOBACCO USERS DON T PLAN TO FAIL. MOST FAIL TO PLAN. Clinicians have a professional obligation to address tobacco use and can have an important role in helping patients plan for their quit attempts. Failure to address tobacco use tacitly implies that quitting is not important. Barzilai et al. (21). Prev Med 33:9 99. THE DECISION TO QUIT LIES IN THE HANDS OF EACH PATIENT. DR. GRO HARLEM BRUNTLAND, FORMER DIRECTOR-GENERAL of the WHO: If we do not act decisively, a hundred years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked. USDHHS. (21). Women and Smoking: A Report of the Surgeon General. Washington, DC: PHS. Copyright The Regents of the University of California and the American Society of Anesthesiologists. All rights reserved. Updated October