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Saving Smokers’ Lives: Evidence Based Strategies Joel L. Nitzkin, MD at AAPHP Session at AMA HOD Chicago, Ill June 15, 2013 June 15, 2013 AAPHP at AMA.

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Presentation on theme: "Saving Smokers’ Lives: Evidence Based Strategies Joel L. Nitzkin, MD at AAPHP Session at AMA HOD Chicago, Ill June 15, 2013 June 15, 2013 AAPHP at AMA."— Presentation transcript:

1 Saving Smokers’ Lives: Evidence Based Strategies Joel L. Nitzkin, MD at AAPHP Session at AMA HOD Chicago, Ill June 15, 2013 June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies Slide 1

2 Today’s Presentation  Tobacco Harm Reduction (THR)  Cessation  Related Topics o E-cigarettes o Attractiveness to teens and other non- smokers  Myths, Barriers and Bottom Lines  Q and A June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies Slide 2

3 THR Intended to Reduce Risk of Death in Smokers  Cigarettes – 443,000 o Current and former smokers 394,000 o Secondhand smoke 49,000 o (numbers stable since 2004) o (CDC estimated deaths per year in USA)  THR (projected if all smokers had used smoke-free products) o Current and former tobacco users <8,000 o Secondhand smoke 0  Vehicular deaths (for comparison) 33,000 Slide 3June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies

4 Promises of THR  Save lives of smokers  No risk to non-smokers  No risk of fire  No costs for drugs or counseling  Free choice and market forces  Could be less attractive to teens  Could be less addictive June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies Slide 4

5 Cigarettes v. Smokeless  Cigarettes o Products of combustion inhaled deep into lung o Sticky tar in lung – exposure continues 24/7  Smokeless o No products of combustion o No tar o Exposure brief Slide 5June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies

6 Slide 6 Blood Nicotine Levels from Cigarettes,Snus, and NRT (Adapted from N Benowitz. NEJM 319: 1318-1330, 1988) June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies

7 American Smokeless Tobacco Moist Snuff Chewing Tobacco (Powdered Dry Snuff) June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies Slide 7

8 Snus and Dissolvables June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies Slide 8

9 E-cigarettes June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies Slide 9

10 Slide 10 Smokeless Tobacco and Oral Cancer Lee and Hamling, BMC Medicine 2009 Oropharynx Cancer AllSince 1990 All1.79 (1.36 – 2.36) 1.28 (0.94 – 1.76) Smoke Adjusted1.36 (1.04 – 1.77) 1.00 (0.83 – 1.20) Smoke-Alcohol Adj1.07 (0.84 – 1.37) 1.07 (0.84 – 1.37) Nine recent studies from Scandinavia and the U.S. show no risk* *Weitkunat et al., BMC Public Health, 2007. June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies

11 Slide 11 Smokeless Tobacco and Cancer Risk Lee and Hamling, BMC Medicine 2009 Site (No. Studies)RR (95% CI)- Smoking Adjusted Esophagus (7)1.1 (0.95 – 1.4) Stomach (8)1.0 (0.9 – 1.2) Pancreas (7)1.1 (0.7 – 1.6) Any Digestive (5)0.9 (0.6 – 1.3) Larynx (2)1.3 (0.6 – 3.0) Lung (6)1.0 (0.7 – 1.4) Prostate (4)1.3 (1.1 – 1.6) Bladder (10)1.0 (0.7 – 1.3) Kidney (5)1.1 (0.7 – 1.7) Lymphoma (3)1.4 (0.6 – 2.9) AllCancer (7)1.0 (0.8 – 1.2) June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies

12 Slide 12 Smokeless Tobacco Use and Cardiovascular Diseases 14 epidemiologic studies 2 meta-analyses Relative Risk Among ST Users: Heart AttackStroke 1 Lee, 20071.12 (0.99 – 1.27)1.42 (1.29 – 1.57) 2 Boffetta-Straif, 20090.99 (0.89 – 1.10)1.19 (0.97 – 1.47) 1 International Journal of Epidemiology 36: 789-804, 2007 2 BMJ Aug 18 (online), 2009 June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies

13 Efficacy of Pharmaceutical Cessation Protocols  Currently available evidence-based pharmaceutical protocols fail more than 90% of smokers who use them, even under the best of study conditions (Moore et al BMJ 338:b1024 2009) June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies Slide 13

14 NRTs and Smokeless Tobacco for Smoking Cessation, Men in the U.S., 2000 MethodAttempted*% Former% Current All 39.3 61 39 Nicotine Patch 2.9 35 65 Nicotine Gum 1.0 34 66 Bupropion 1.1 29 71 Nicotine Inhaler 0.098 28 72 Nicotine Spray 0.014 0 100 Switch to ST 0.36 73 27 *Numbers in millions Rodu and Phillips, Harm Reduction Journal 5: 18, 2008 June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies Slide 14

15 Dual Use and Smokeless Tobacco (Frost-Pineda et al Nicotine and Tobacco Research 2010)  Starting as smokers – 4 year F.U. USA o Cigarettes only 82% o Dual use 4% o Smokeless only 2% o Tobacco Abstinent 12%  Starting as dual users – 4 year F.U. USA o Cigarettes only 28% o Dual use 44% o Smokeless only 14% o Tobacco Abstinent 10%  Morbidity and mortality reflect cigarette use, no unique harm from dual use June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies Slide 15

16 Cessation – Allen Carr published data  Of 357 smokers attending A.C. seminar in Austria, 2002, 308 consented to FU, 223 (72%) followed up; 40% were abstinent at 1 year (29% of the 308) (Hutter et al: Int Arch Occcup Env Health 79:42- 8, 2006)  Of 515 employees of a steel plant attending A.C. seminar, 510 responded, with 51.4% reporting continued abstinence at 3 years, random sample of 61 respondents, urine cotinine showed high agreement with smoking history. (Mosshammer and Neuberger Addictive Behaviors 32(7) 1486-93 2007) June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies Slide 16

17 Notes on e-cigarettes  Morgan Stanley’s David Adelman estimates e- cigarettes will replace 1.5 Billion cigarettes on the market this year, up from 600 million in 2012. (http://au.businessinsider.com/chart-e-cigarette-growth-20132-14)http://au.businessinsider.com/chart-e-cigarette-growth-20132-14  E-cigarettes only tobacco/nicotine product with huge, vocal, politically active users groups not affiliated or supported by manufacturers or vendors June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies Slide 17

18 Dual Use and E-Cigarettes  Survey of 1,347 e-cigarette users from 33 countries recruited from two e- cigarette web sites (Dawkins et al Addiction 108(6) 11115-25 2013) o 57% have not smoked “for months” after quitting, using e-cigarette to quit o 88% either quit or cut down substantially on cigarettes smoked June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies Slide 18

19 Smokers Uninterested in Quitting  Six month pilot study (Italy) smokers uninterested/unwilling to quit 9/40 (22.5%) abstinent at 6 months; 22/40 (55%) abstinent or 50% reduction in smoking; 88% reduced cigarette consumption (Polosa et al BMC Public Health 11:786 2011)  Twelve month pilot study (Italy) schizophrenic smokers uninterested in quitting abstinence at 12 months 2/14 (14.4%) abstinent or 50% reduction in 9/14 (64.3%) (Caponnetto et al Int J Environ Res Public Health 10(2) 446-61 2013) June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies Slide 19

20 Attractiveness to Teens and other non-smokers (re smoke-free alternatives compared to cigarettes)  No pandemic of tobacco use prior to predatory marketing of machine-made cigarettes  30% of smokers can satisfy their urge to smoke with zero-nicotine from e-cigarette (Eissenberg Tobc Control 19: 87-8 2010)  Non-smokers know about e-cigarettes, but don’t use them despite unrestricted marketing o National (US) study of 3,240 adults could only find 6 non- smokers who have ever tried e-cigarettes (McMillen et al J Env Pub H Article ID 98974, 2012) o ASH (Great Britain) commissioned survey of 12,171 adults and 2,178 children age 11-18 could not find a single non- smoker, youth or adult that regularly used e-cigarettes (www.ash.org.uk Fact Sheet May 2013)www.ash.org.uk June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies Slide 20

21 Myths  Pharmaceutical smoking cessation products are highly effective  Smokeless tobacco (in USA) causes oropharyngeal cancer  Nicotine is responsible for much, if not most of the cardiovascular mortality of cigarettes  Lack of FDA approval of e-cigarettes is because e-cigarettes fail to meet FDA standards June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies Slide 21

22 Barriers to THR  Usual interpretation of goal of “tobacco free society” o Unwillingness to consider use of non-pharmaceutical tobacco products in public health initiative  Mandated warnings on smokeless o Mouth cancer o Tooth and gum disease o “not safe alternative” o (addictive)  Lack of biomarkers  10+ year “incubation” initiation of smoking to onset of disease  Impossibility of ultimate controlled clinical trial June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies Slide 22

23 Purpose of AAPHP Resolutions  -- pave way for development of new evidence- based strategies to save smokers’ lives and reduce nicotine addiction  Separation of smoking cessation from nicotine cessation for smokers unable or unwilling to quit  Replacement of cigarettes with less attractive and less addictive products as new approach to reducing nicotine addiction  New approaches to cigarette and/or tobacco cessation o Intensive cognitive-behavioral therapy with self- reinforcement o ?? Other new approaches ?? June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies Slide 23

24 Joel L. Nitzkin, MD, MPH, DPA  JLN, MD Associates, LLC  AAPHP Tobacco Control Task Force and Policy Committee 2007-2012  Associate Fellow, Tobacco Control, R Street Institute  (504) 899-7893  Jln@jln-md.com Jln@jln-md.com  New Orleans, LA  www.aaphp.org/tobacco www.aaphp.org/tobacco  www.rstreet.org www.rstreet.org June 15, 2013 AAPHP at AMA HOD Chicago Nitzkin: Saving Smokers' Lives: Evidence-Based Strategies Slide 24

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