With special thanks to Dr. Ron Laporte at With special thanks to Dr. Ron Laporte at University of Pittsburgh for emailing and University of Pittsburgh for emailing and

providing me with valuable material and data providing me with valuable material and data to be used in this presentation……….to be used in this presentation……….Nayyar R. Nayyar R.

KazmiKazmi

There are almost 10-15 million There are almost 10-15 million established smokers in Pakistanestablished smokers in Pakistan

Common in labourer class, Common in labourer class, transport drivers, other lower socio-transport drivers, other lower socio-economic groups as well as upper economic groups as well as upper stratum of the societystratum of the society

Drug AddictsDrug Addicts Non Drug AddictsNon Drug Addicts

Established Established SmokersSmokers 257257 6262

Non-SmokersNon-Smokers 3939 134134

Kazmi NR, et al. Regular smoking as a risk factor in drug addicts- A case control study in Peshawar- Int Journal of Epidemiology: 2000. Vol.XXI, No.IV: 1554

Odds Ratio 14.24

Have you ever smoked a whole cigarette?

Ever tried – even a few puffs?

No – Never SmokerNever Smoker Yes

YesNo – TrierTrier Smoked > 1 whole cigarette?

No – TrierTrier Yes

On how many of last 30 days did you smoke?

None – < Monthly smoker< Monthly smoker < 20 days > 20 days – Established smokerEstablished smoker

On how many of last 7 days did you smoke?

None – Experimental SmokerExperimental Smoker At least one – Regular SmokerRegular Smoker

11

22

22

33

44 55

Stage Model of Smoking AcquisitionStage Model of Smoking Acquisition

66

Smoking by Age and Smoking by Age and Stage of Onset*Stage of Onset*

AGE*Source: The MACC Study

Tobacco Dependence as a Tobacco Dependence as a Chronic DiseaseChronic Disease

Tobacco dependence demonstrates Tobacco dependence demonstrates features of a chronic disease:features of a chronic disease: Long-term disorderLong-term disorder Periods of relapse and remissionPeriods of relapse and remission Requires ongoing rather than acute careRequires ongoing rather than acute care

Smoking in PerspectiveSmoking in Perspective Kills more than 440,000 Americans each yearKills more than 440,000 Americans each year 23% of adult Americans smoke23% of adult Americans smoke 3,000 children and adolescents become regular 3,000 children and adolescents become regular

tobacco users every daytobacco users every day Causes cancer, heart disease, stroke, pulmonary Causes cancer, heart disease, stroke, pulmonary

disease, and adverse pregnancy outcomes- shortens disease, and adverse pregnancy outcomes- shortens life expectancy 14 yearslife expectancy 14 years

Adds $157 billion in costs per yearAdds $157 billion in costs per year One-third of all tobacco users in U.S. will die One-third of all tobacco users in U.S. will die

prematurelyprematurely

Environmental Tobacco SmokeEnvironmental Tobacco Smoke Kills one person prematurely, for every 8 people killed by primary smokingKills one person prematurely, for every 8 people killed by primary smoking

50,000 premature deaths each year50,000 premature deaths each year 1 million ER visits for asthma each year1 million ER visits for asthma each year

Causes all diseases primary smoke Causes all diseases primary smoke 60 carcinogens-formaldehyde, benzo[a]pyrene60 carcinogens-formaldehyde, benzo[a]pyrene 6 developmental toxicants, nicotine, CO6 developmental toxicants, nicotine, CO

The tobacco industry spends billions arguing the pointThe tobacco industry spends billions arguing the point

Perceived Health Risks Among Cigarette Smokers

Heart attack Cancer

All smokers 29% 40%

Heavy smokers 39% 49%

Ayanian & Cleary JAMA 1999;281:1091-1021

Predictive Factors of Youth Smoking Predictive Factors of Youth Smoking OnsetOnset

EnvironmentalEnvironmental

Access to cigarettesAccess to cigarettes Exposure to marketingExposure to marketing Peer use and supportPeer use and support Sibling use and supportSibling use and support Parental supportParental support Normative expectationsNormative expectations

BehavioralBehavioral

Academic achievementAcademic achievement Behavioral skillsBehavioral skills Prior use of tobaccoPrior use of tobacco Other problem behaviorsOther problem behaviors

Socio-DemographicSocio-Demographic

Low SESLow SES Developmental stageDevelopmental stage

Intra-PersonalIntra-Personal

Functional meanings of Functional meanings of smokingsmoking

Low self-imageLow self-image Self-efficacy to refuse offersSelf-efficacy to refuse offers Personality factorsPersonality factors

Exposure to advertising, adult/sibling role models Exposure to advertising, adult/sibling role models who smoke cigarettes, and low academic who smoke cigarettes, and low academic achievementachievement

Peer influences to smoke, the perception that Peer influences to smoke, the perception that smoking is normative and functional, and social smoking is normative and functional, and social access to cigarettes.access to cigarettes.

Social situations and peers that support smoking, Social situations and peers that support smoking, low self-efficacy and skills to refuse offers to low self-efficacy and skills to refuse offers to smoke, and social/commercial access to cigarettes.smoke, and social/commercial access to cigarettes.

Peers who smoke, the perception that smoking has Peers who smoke, the perception that smoking has personal utility, social and commercial access to personal utility, social and commercial access to cigarettes, and few restrictions on smoking in the cigarettes, and few restrictions on smoking in the home, school, and community settings.home, school, and community settings.

Number of cigarettes smoked, frequency of Number of cigarettes smoked, frequency of smoking, self-efficacy to refuse offers, peer smoking, self-efficacy to refuse offers, peer support for smoking, and other problem behaviors.support for smoking, and other problem behaviors.

Stages of Smoking Onset and Stages of Smoking Onset and Predictive Factors among YouthPredictive Factors among Youth

It is essential that clinicians and It is essential that clinicians and health care delivery systems health care delivery systems (including administrators, (including administrators, insurers, and purchasers) insurers, and purchasers) institutionalize the consistent institutionalize the consistent identification, documentation, identification, documentation, and treatment of every tobacco and treatment of every tobacco user seen in a health care user seen in a health care setting.setting.

Brief tobacco dependence Brief tobacco dependence treatment is effective, and treatment is effective, and every patient who uses every patient who uses tobacco should be offered tobacco should be offered at least brief treatment.at least brief treatment.

Assessment of Tobacco UseAssessment of Tobacco Use

Does Patient Now UseTobacco?

Did PatientOnce Use?Tobacco?

PreventRelapse

PromoteMotivation

To Quit

ProvideAppropriateTreatments

Is Patient NowWilling To Quit?

EncourageContinuedAbstinence

YES NO

YES NO YES NO

Patient Presents to aHealth Care Setting

Two Questions, Three MinutesTwo Questions, Three MinutesVery Brief CounselingVery Brief Counseling

Do you smoke?Do you smoke? Do you want to quit?Do you want to quit?

If yes-If yes- provide advice provide advice set quit dateset quit date prescribe medsprescribe meds set follow-upset follow-up

If no-provide advice and move onIf no-provide advice and move on

PharmacotherapiesPharmacotherapies

Numerous effective pharmacotherapies for Numerous effective pharmacotherapies for smoking cessation now exist. Except in smoking cessation now exist. Except in the presence of contraindications, these the presence of contraindications, these should be used with all patients should be used with all patients attempting to quit smoking.attempting to quit smoking. Six Six first-linefirst-line pharmacotherapies were pharmacotherapies were

identified that reliably increase long-term identified that reliably increase long-term smoking abstinence rates:smoking abstinence rates: Bupropion SRBupropion SR • Nicotine Nasal Spray• Nicotine Nasal Spray Nicotine GumNicotine Gum • Nicotine Patch• Nicotine Patch Nicotine InhalerNicotine Inhaler Nicotine Lozenge Nicotine Lozenge

The “5 R’s” to Enhance Motivation The “5 R’s” to Enhance Motivation for Patients Unwilling To Quitfor Patients Unwilling To Quit

RELEVANCERELEVANCE: Tailor advice and discussion to : Tailor advice and discussion to each patienteach patient

RISKSRISKS: Discuss risks of continued smoking: Discuss risks of continued smoking REWARDSREWARDS: Discuss benefits of quitting: Discuss benefits of quitting ROADBLOCKSROADBLOCKS: Identify barriers to quitting: Identify barriers to quitting REPETITIONREPETITION: Reinforce the motivational : Reinforce the motivational

message at every visitmessage at every visit

Types of Prevention Programs for Types of Prevention Programs for YouthYouth

School-based curriculaSchool-based curricula School environmental changesSchool environmental changes Parental involvementParental involvement Teen cessation programsTeen cessation programs Social and commercial access strategiesSocial and commercial access strategies Mass media campaignsMass media campaigns Cigarette advertising and promotional bansCigarette advertising and promotional bans Price increasesPrice increases

Sources of MOST RECENT Cigarette: Sources of MOST RECENT Cigarette: Past Month Smokers, Grades 8-10Past Month Smokers, Grades 8-10

N = 3991N = 3991Source: Forster et al, under review.

Mass Media Strategies Mass Media Strategies Aimed at YouthAimed at Youth

Pros ConsReach large numbersReach large numbersof teensof teens

Can change social Can change social normsnorms

Can be linked to more Can be linked to more intensive interventions intensive interventions

Message may not be Message may not be relevantrelevant

Superficial prevention Superficial prevention messagemessage

Expensive on primary Expensive on primary networksnetworks

Needs frequent updating Needs frequent updating

Types:Types: Television counter-advertising, radio ads, Television counter-advertising, radio ads, print media, internetprint media, internet

Tobacco Advertising Continues Tobacco Advertising Continues in Youth-Oriented Magazinesin Youth-Oriented Magazines

Thank you for Thank you for NOT SmokingNOT Smoking