1. Tobacco In North Dakota Eric L. Johnson, M.D. Assistant Professor Department of Family and Community Medicine University of North Dakota School of Medicine and Health Sciences Physician Consultant North Dakota Tobacco Quitline/Quitnet Assistant Medical Director Altru Diabetes Center

2. Objectives Review Tobacco Related Disease in the U.S. and in North Dakota Understand Negative Health Effects of Second Hand (Passive) Smoke Review Negative Economic Impact of Tobacco Review High Quality Tobacco Cessation Resources in North Dakota

4. Tobacco Use in North Dakota ~20% of U.S. Adults smoke (41% in 1965) ~18% of ND adults smoke (~21% when Quitline launched 2004) 41% of ND Native Americans smoke 18% of Pregnant women in ND smoke vs. 12% in the U.S. CDC ND Dept of Health

5. Tobacco Use in North Dakota ~116,000 ND adults and ~8,000* HS students smoke cigarettes ~20,000 ND adults and ~3,800^ HS students use spit tobacco (BRFSS 2008) (YRBS 2005,2007)

6. North Dakota Department of Health Division of Tobacco Prevention and Control

7. North Dakota Department of Health Division of Tobacco Prevention and Control

8. Tobacco Use in North Dakota Native American population: 49.3% adults use tobacco (highest smoking rate of any ethnic group in U.S.) Smoking in pregnancy higher in North Dakota than national average: 18% vs. 12% WIC Clinic population survey: 45% smoked prior to pregnancy vs. 16% non-WIC

9. Tobaccos Health Cost in North Dakota Smoking-attributable direct medical expenditures: $250,000,000 Smoking-attributable productivity costs: $192,000,000 Medicaid expenditures for smoking-related illnesses and diseases: $47,000,000 Annual Costs! CDC. Smoking-Attributable Mortality, Morbidity and Economic Costs (SAMMEC) report, 2008. CDC Data Highlights, 2006.

10. North Dakota spends $691 per capita on direct medical expenditures and lost productivity due to smoking

11. Tobacco Use in North Dakota Heart Disease and Cancer are the leading causes of death in North Dakota Tobacco use is the leading preventable cause of death

12. Smoking Causes Death Smoking causes approximately 90% of all lung cancer deaths in men 80% of all lung cancer deaths in women 90% of deaths from chronic obstructive lung disease (COPD) CDC

13. Smoking Causes Death Compared with nonsmokers smoking increases risk of Coronary heart disease by 2 to 4 times Stroke by 2 to 4 times Men developing lung cancer by 23 times Women developing lung cancer by 13 times Dying from chronic obstructive lung diseases (COPD) by 12 to 13 times Also associated with risk of type 2 diabetes CDC

14. Secondhand Smoke (Passive Smoking) Negative effects of smoke on people who arent doing the smoking No longer speculation that this is dangerous for those exposed to secondhand smoke

15. Secondhand Smoke Deaths United States Lung cancer – 3,000 deaths annually Heart Disease – 35,000 deaths annually North Dakota 80-140 deaths annually CDC American Cancer Society

16. Second Hand Smoke and Cardiovascular Risk (Heart Attack) Cardiovascular Risk (Heart Attack) is ~80-90% of primary smoking Secondhand smoke increases risk of heart attack by 30% Well understood phenomenon- no longer speculative concerning harmful effects Barnoya A, Glantz S Circulation May 24 2005 The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General 2006

17. Smoking Ban Smoking Ban is not an appropriate description More descriptive…. Comprehensive Smoke Free legislation Smoke Free Policy

18. Smoke Free Legislation Typically, legislation that eliminates smoking in public places The smoker is NOT the medical focus of this type of legislation (not protecting the smoker from themselves) Focus in on reducing injury inflicted on others Business impact (negative) is little or none (recent Fargo area survey, others)

19. Smoke Free Legislation and Heart Attack LocationPopulation Change in Heart Attack Hospital Admissions Helena 68,140 40% Pueblo 698,229 (2counties) 41% New York 18,976,457 8% Indiana 239,332 50% Ohio 29,636 20% Saskatoon 202,340 13%

20. Communities Similar to Grand Forks Pueblo, CO Population 103,648 College Town Decrease in Heart Attacks following smoking ban 27%

21. Communities Similar to Grand Forks Bowling Green, OH Population 29,636 College Town Reduction in Heart Attacks following smoking ban 19%

22. Communities Similar to Grand Forks Helena, MT Population 47,154 College Town Reduction in Heart Attack with smoking free legislation 40% Increase in Heart Attacks following smoke free legislation repeal 40%

23. Smoke Free Legislation and Heart Attack 11 legitimate studies Europe, U.S., Canada Approx 17% reduction in Heart Attack across all studies Approx 195,000 Heart Attacks would be avoided in U.S. annually In an age of health care cost containment, cant disregard

24. Long Term Tobacco Control California has longest running law in U.S. Reduction in adult smoking 40% 1998-2006 Reduction in lung cancer 4 times faster than rest of U.S. Maine, New York, Washington 45-60% reduction in youth smoking CDC MMWR 9-10-10

25. Tobacco Cessation

26. Nicotine is addictive…and this is precisely why it is there The cigarette is a highly engineered nicotine delivery device Chemicals like ammonia are added to release more nicotine Nicotine is there on purpose, for a purpose Nicotine is not a carcinogen (patients may not know this)

27. Pharmacotherapy (Medications) For Tobacco Cessation

28. Pharmacotherapy(Medications) Nicotine replacement therapy (NRT) –Gum –Patch –Spray –Inhaler –Lozenge Bupropion (Zyban, Wellbutrin) Varenicline (Chantix) All are considered 1 st line treatment

29. Medications typically will give better results when combined with counseling USPHS Guidelines 2008

30. Effective, High Quality Counseling Exists to Assist in Quitting Tobacco in North Dakota- NO cost to user to access

31. Tobacco Quitlines Web Based Cessation Both are individualized, population-based, clinically effective Quitlines are specifically endorsed by U.S. Public Health Service for Tobacco Cessation

32. North Dakota Tobacco Quitline North Dakota Quitnet

33. Free to all North Dakota residents Up to 5 telephone counseling sessions Counselors are in North Dakota at UND FREE Nicotine replacement therapy (gum, patches) for qualifying 7-month quit rate 34% * 13-month quit rate 33% * 3-5% quit rate with no support *June 2010

34. nd.quitnet.com Free to all North Dakota Residents

35. North Dakota Tobacco Quitline Launched Sept. 2004 Large roll-out to ND providers- ~1800 providers received face to face or teleconference CME information from UND (Dr. Johnson and Dr. Anel) Continues to have excellent acceptance by North Dakota Providers

36. Client Satisfaction

37. North Dakota Tobacco Cessation North Dakota Has High Quality, well respected Options Quitline: Thousands of Clients since 2004 Quitnet: Good roll-out since Feb. 2010 ~ 670 registered users through 9/5/10 These 2 services are integrated- ease of use These programs have high acceptance by North Dakota Providers and clients

38. Other Tobacco Control Incentives Several studies in the U.S. and Europe have shown that increasing tobacco taxes tend to drive down smoking rates California has shown that every $1 spent on tobacco control has saved $50 in their health care system-net savings is $80-$100 billion over 20 years Tob Control - 01-APR-2010; 19 Suppl 1: i68-76 Health Policy. 2007 Jul;82(2):142-52 PLoS Med - 26-AUG-2008; 5(8): e178

39. Summary Tobacco Related diseases have significant impact on overall morbidity and mortality in North Dakota and the U.S. Tobacco Cessation has a positive impact on many disease states and is cost effective Tobacco Use is a Habit and an Addiction Effective telephone based counseling and/or web-based counseling is an effective tool in Tobacco Cessation

40. Acknowledgements North Dakota State Department of Health, Division of Tobacco Prevention and Control University of North Dakota School of Medicine and Health Sciences Department of Family and Community Medicine Mayo Clinic Tobacco Quitline Dr. Donna A. Anel Healthways Inc.