1. Risk Factors for Smoking in the EMR Region Kawkab Shishani, BSN, PhD The Hashemite University Risk Factors for Smoking in the EMR Region Kawkab Shishani, BSN, PhD The Hashemite University Epidemiology of Diabetes & Other Non- Communicable Diseases Alexandria, Egypt 6-13 th January 2009

2. Petra: Jordan’s Wonder of the World

3. Objectives 1.Describe the scope of the problem 2.Examine smoking among selected populations 3.Differentiate between forms of tobacco use 4.Discuss why smoking is harmful 5.Value WHO position on tobacco control 6.Summarize how health care professionals can provide the leadership in tobacco control

4. Question Why is it important to study smoking ? 1. Smoking is the chief avoidable risk factor for NCDs 2. Smoking Affects the progression of NCDs (> complications) 3. Unlike the other risk factors such as physical activity and nutrition that affects only those who do not comply to them, smoking affects smoker as well as those around

5. Why Do Farmers Grow Tobacco? The wealth generated by leaf tobacco production helps to improve quality of life and attracts educational, health and social facilities in, otherwise, relatively impoverished, rural areas. International tobacco growers association http://www.tobaccoleaf.org/about_itga/index.asp?op=1

6. Scope of the Problem  1,3 billion smokers:  80% in developing countries  20% in developed countries  The number is expected to increase by 1.7 per cent annually  By 2030, 80% of deaths due to tobacco will occur in developing countries

7. Scope of the Problem  Most cigarettes consumed worldwide are international brands  As smoking rates in the US and Europe is declining, new markets are needed  Globalization made it easy for companies to access new markets internationally (Asia, Africa, Middle East)

8. Smoking: Men and Women  Global smoking (M: 4> F)  ↑ in smoking rates in F > M  Ratio of smoking M: F  Developed countries 3:1  Developing countries 7:1

9. Smoking: Men and Women EMR country profilehttp://www.emro.who.int/TFI/CountryProfile

10. Smoking: Men and Women  50%-66% of women use “light”  Addiction in M>F  Biological responses to nicotine differ between M & F  Smoking in women is reinforced by less nicotine than in men (Perkins et al., 1991)

11. Female Smoking & Low Birth Weight www.globalheathfactt.org

12. Smoking: Youth WHO (2007). Sifting the evidence: Gender and tobacco control

13. Youth Smoking in EMR EMR country profilehttp://www.emro.who.int/TFI/CountryProfile

14. I can't stop smoking. I am addicted to cigarettes. Smoking: Youth  Parent (father smokes)  Access to cigarettes  Peer pressure  Experimentation  Imitating adults

15. Smoking: Health Professionals

16. GHPS: Jordan CharacteristicWomen % (n) Men % (n) Total % (n) Once started clinical work smoking Decreased Stayed the same Increased Do you want to quit smoking Yes No Have you ever tried to quit Yes No How many times you tried to quit 1-3 times 34.4 (32) 35.5 (33) 30.1 (93) 62.0 (54) 37.9 (33) 54.9 (50) 45.1 (41) 77.8 (28) 24.2 (104) 34.7 (149) 41.0 (176) 52.0 (216) 48.0 (199) 61.9 (255) 38.1 (157) 37.9 (161) 26.1(136) 34.9 (182) 39.1 (204) 53.8 (270) 46.2(232) 60.6(305) 39.4 (198) 74.4 (189)

17. Learning Need Assessment Nurses % Physician s % Total % Cigarettes and argileh are both addicting Taught in classes about dangers of smoking Discuss in any of your classes why people smoke Ever received any formal training in smoking cessation Provide materials to support smoking cessation to patients 37.2 65.7 53.1 35.9 54.2 52.2 72.5 60.6 26.6 63.6 41.9 67.6 55.1 32.3 56.9 GHPS: Jordan

18. Forms Of Tobacco Use Waterpipe  Waterpipe  Cigarettes  Chewing

19. Second Hand Smoking  At home:  Smoking around children  Children prepare waterpipe for parents  Cultural issues  Public places (hospitals, buses, taxis,..)

20. Waterpipe: The Emerging Epidemic Myths: Myths:  It is safe alternative for cigarettes (WHO study group, 2005)  Chemicals filtered by the water (bubbling)  Not addictive; can quit anytime (Asfar et al. BMC Public Health 2005) Highest rates are in MENA (Shihadeh., 2004) Highest rates are in MENA (Shihadeh., 2004) Social practice (Café employees) Social practice (Café employees) Children smoke with their parents (Maziak et al., 2004) Children smoke with their parents (Maziak et al., 2004)

21. Waterpipe: The Emerging Epidemic  Nicotine in 1 head of unflavored tobacco = 70 regular cigarettes;  Flavored tobacco = 20cigarettes  A single smoking session: 2.25 mg nicotine, high levels of arsenic, cobalt, chromium, and lead (Shihadeh, 2003)  Cotinine levels are almost the same among waterpipe and cigarette smokers (Bacha, Salameh, Waked, 2007)

22. Chemicals Produced From Smoking  Nicotine  Tar  Carbon monoxide  Benzopyrene  Cyanide hydrogen

23. How Does Nicotine Work? From Benowitz N. Nicotine Addiction. Primary Care 1999; 26(3):611-31

24. Why Nicotine Matters Short term effectLong term effect

25. Tobacco Dependence: A Chronic Disease  The long delay between the onset of smoking and associated morbidities  70% of the smokers want to quit Unsuccessful  44% tried to quit  Only 7% succeed

26. Tobacco Dependence: A Chronic Disease  A Chronic disease model:  Long term nature  Minimum number achieve permanent abstinence  Periods of relapse and remissions  No ideal intervention  Emphasis on education and counseling (same like in DM, HTN) (US Department of Health and Human Services, 2008)

27. WHO Efforts to Control Tobacco Use (FCTC)  Price and tax measures  Protection from exposure to tobacco smoke  Educational and public awareness programmes  Promoting the cessation of tobacco use  Sales to and by minors  Research, surveillance and exchange

28. Where Do We Go From Here?  Monitoring tobacco use to provide accurate tracking of epidemiological data about the extent of tobacco exposure (GTSS)  Report morbidities associated with smoking  Public Education (media, curricula)  Health Insurance companies (reimburse tobacco dependence treatments)

29. Why Do We Need A Plan in EMR  Lack of human resources (experienced in tobacco control  Lack of adequate studies on hazards of smoking  Research encouragement (Funding) http://www.emro.who.int/tfi/CountryProfile-Part6.

30. 2008 Update

31. Identifying Tobacco Users a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis. Screening System Estimated Abstinence Rate (95% C.I.) No screening system in place to identify smoking status (reference group) 3.1 Screening system in place to identify smoking status 6.4 (1.3–11.6) Meta-analysis (1996): Impact of having a tobacco use status identification system in place on abstinence rates among patients who smoke (n = 3 studies) a

32. Physicians Should Advise AdviceEstimated Abstinence Rate No advice to quit (reference group)7.9 Physician advice to quit10.2 (8.5–12.0) Meta-analysis (1996): Effectiveness of and estimated abstinence rates for advice to quit by a physician (n = 7 studies) a a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.

33. Intensity of Clinical Interventions Level of ContactEstimated Abstinence Rate (95% C.I.) No Contact10.9 Minimal counseling (< 3 minutes) 13.4 (10.9–16.1) Low-intensity counseling (3-10 minutes) 16.0 (12.8–19.2) Higher intensity counseling (> 10 minutes) 22.1 (19.4–24.7) Meta-analysis (2000): Effectiveness of and estimated abstinence rates for various intensity levels of session length (n = 43 studies) a a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.

34. Total Amount Of Contact Time Total Amount of Contact Time Estimated Abstinence Rate (95% C.I.) No minutes11.0 1–3 minutes14.4 (11.3–17.5) 4–30 minutes18.8 (15.6–22.0) 31–90 minutes26.5 (21.5–31.4) 91–300 minutes28.4 (21.3–35.5) > 300 minutes25.5 (19.2–31.7) Meta-analysis (2000): Effectiveness of and estimated abstinence rates for total amount of contact time (n = 35 studies) a a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.

35. Number Of Sessions Number of SessionsEstimated Abstinence Rate (95% C.I.) 0–1 session12.4 2–3 sessions16.3 (13.7–19.0) 4–8 sessions20.9 (18.1–23.6) > 8 sessions24.7 (21.0–28.4) Meta-analysis (2000): Effectiveness of and estimated abstinence rates for number of person-to-person treatment sessions (n = 46 studies) a a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.

36. Type of Clinician Estimated Abstinence Rate (95% C.I.) No clinician 10.2 Self-help10.9 (9.1–12.7) Non-physician clinician15.8 (12.8–18.8) Physician clinician19.9 (13.7–26.2) Meta-analysis (2000): Effectiveness of and estimated abstinence rates for interventions delivered by different types of clinicians (n = 29 studies) a a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.

37. Type of Clinician a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis. Number of Clinician TypesEstimated Abstinence Rate (95% C.I.) No clinician 10.8 One clinician type18.3 (15.4–21.1) Two clinician types23.6 (18.4–28.7) Three or more clinician types23.0 (20.0–25.9) Meta-analysis (2000): Effectiveness of and estimated abstinence rates for interventions delivered by various numbers of clinician types (n = 37 studies) a

38. Formats of Psychosocial Treatments Format Number Estimated Abstinence Rate (95% C.I.) No format10.8 Self-help12.3 (10.9–13.6) Proactive telephone counseling13.1 (11.4–14.8) Group counseling13.9 (11.6–16.1) Individual counseling16.8 (14.7–19.1) Meta-analysis (2000): Effectiveness of and estimated abstinence rates for various types of formats (n = 58 studies) a a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.

39. Quitlines Intervention Estimated Abstinence Rate (95% C.I.) Minimal or no counseling or self-help 10.8 Quitline counseling12.7 (11.3–14.2) Meta-analysis (2008): Effectiveness of and estimated abstinence rates for quitline counseling compared to minimal interventions, self-help, or no counseling (n = 9 studies) a Intervention Estimated Abstinence Rate (95% C.I.) Medication alone 23.2 Medication and quitline counseling28.1 (24.5–32.0) Meta-analysis (2008): Effectiveness of and estimated abstinence rates for quitline counseling and medication compared to medication alone (n = 6 studies ) a a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.

40. Treatment Elements Type of Counseling and Behavioral Therapy Estimated Abstinence Rate (95% C.I.) No counseling/behavioral therapy11.2 Relaxation/breathing10.8 (7.9–13.8) Contingency contracting11.2 (7.8–14.6) Weight/diet11.2 (8.5–14.0) Cigarette fading11.8 (8.4–15.3) Negative affect13.6 (8.7–18.5) Intratreatment social support14.4 (12.3–16.5) Extratreatment social support16.2 (11.8–20.6) Practical counseling (general problem solving/ skills training) 16.2 (14.0–18.5) Other aversive smoking17.7 (11.2–24.9) Rapid smoking19.9 (11.2–29.0) Meta-analysis (2000): Effectiveness of and estimated abstinence rates for various types of counseling and behavioral therapies (n = 64 studies) a a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.

41. Treatment Elements TreatmentEstimated Abstinence Rate (95% C.I.) Placebo8.3 Acupuncture8.9 (5.5–12.3) Meta-analysis (2000): Effectiveness of and estimated abstinence rates for acupuncture (n = 5 studies) a a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.

42. Combining Counseling & Medication TreatmentEstimated Abstinence Rate (95% C.I.) Medication alone 21.7 Medication and counseling27.6 (25.0–30.3) Meta-analysis (2008): Effectiveness of and estimated abstinence rates for the combination of counseling and medication vs. medication alone (n = 18 studies) a a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis. TreatmentEstimated Abstinence Rate (95% C.I.) 0–1 session plus medication 21.8 2–3 sessions plus medication28.0 (23.0–33.6) 4–8 sessions plus medication26.9 (24.3–29.7) More than 8 sessions plus medication32.5 (27.3–38.3) Meta-analysis (2008): Effectiveness of and estimated abstinence rates for the number of sessions of counseling in combination with medication vs. medication alone (n = 18 studies) a TreatmentEstimated Abstinence Rate (95% C.I.) Counseling alone 14.6 Medication and counseling22.1 (18.1–26.8) Meta-analysis (2008): Effectiveness of and estimated abstinence rates for the combination of counseling and medication vs. counseling alone (n = 9 studies) a

43. First-Line Medications Medication Estimated Abstinence Rate (95% C.I.) Placebo13.8 Monotherapies Varenicline (2 mg/day)33.2 (28.9–37.8) Nicotine Nasal Spray26.7 (21.5–32.7) High-Dose Nicotine Patch ( > 25 mg) (These included both standard or long-term duration)26.5 (21.3–32.5) Long-Term Nicotine Gum (> 14 weeks)26.1 (19.7–33.6) Varenicline (1 mg/day)25.4 (19.6–32.2) Nicotine Inhaler24.8 (19.1–31.6) Clonidine25.0 (15.7–37.3) Bupropion SR24.2 (22.2–26.4) Nicotine Patch (6–14 weeks)23.4 (21.3–25.8) Long-Term Nicotine Patch (> 14 weeks)23.7 (21.0–26.6) Nortriptyline22.5 (16.8–29.4) Nicotine Gum (6–14 weeks)19.0 (16.5–21.9) Combination Therapies Patch (long-term; > 14 weeks) + ad lib NRT (gum or spray)36.5 (28.6–45.3) Patch + Bupropion SR28.9 (23.5–35.1) Patch + Nortriptyline27.3 (17.2–40.4) Patch + Inhaler25.8 (17.4–36.5) Patch + Second generation antidepressants (paroxetine, venlafaxine)24.3 (16.1–35.0) Medications not shown to be effective Selective Serotonin Re-uptake Inhibitors (SSRIs)13.7 (10.2–18.0) Naltrexone7.3 (3.1–16.2) a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis. Meta-analysis (2000): Effectiveness of and estimated abstinence rates for various types of counseling and behavioral therapies (n = 64 studies) a

44. Nicotine Lozenge

45. Relative Effectiveness of Medications MedicationEstimated Odds Ratio (95% C.I.) Nicotine Patch (reference group)1.0 Monotherapies Varenicline (2 mg/day)1.6 (1.3–2.0) Nicotine Nasal Spray1.2 (0.9–1.6) High-Dose Nicotine Patch ( > 25 mg) (standard or long-term)1.2 (0.9–1.6) Long-Term Nicotine Gum (> 14 weeks)1.2 (0.8–1.7) Varenicline (1 mg/day)1.1 (0.8–1.6) Nicotine Inhaler1.1 (0.8–1.5) Clonidine1.1 (0.6–2.0) Bupropion SR1.0 (0.9–1.2) Long-Term Nicotine Patch (> 14 weeks)1.0 (0.9–1.2) Nortriptyline0.9 (0.6–1.4) Nicotine Gum0.8 (0.6–1.0) Combination Therapies Patch (long-term; > 14 weeks) + NRT (gum or spray)1.9 (1.3–2.7) Patch + Bupropion SR1.3 (1.0–1.8) Patch + Nortriptyline0.9 (0.6–1.4) Patch + Inhaler1.1 (0.7–1.9) Second generation antidepressants & Patch1.0 (0.6–1.7) Medications not shown to be effective Selective Serotonin Re-uptake Inhibitors (SSRIs)0.5 (0.4–0.7) Naltrexone0.3 (0.1-0.6) a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis.

46. Precessation NRT Use Meta-analysis (2008): Effectiveness of and abstinence rates for smokers not willing to quit (but willing to change their smoking patterns or reduce their smoking) after receiving NRT compared to placebo (n = 5 studies) a a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis. Intervention Estimated Abstinence Rate (95% C.I.) Placebo3.6 Nicotine replacement (gum, inhaler, or patch) 8.4 (5.9–12.0)

47. Use of Over-the-Counter Medications Meta-analysis (2000): Effectiveness of and estimated abstinence rates for OTC nicotine patch therapy (n = 3 studies) a a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis. OTC Therapy Estimated Abstinence Rate (95% C.I.) Placebo6.7 OTC nicotine patch therapy11.8 (7.5–16.0)

48. Systems Evidence Intervention Estimated Abstinence Rate (95% C.I.) No Intervention 6.4 Clinician Training 12.0 (7.6–18.6) a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis. Intervention Estimated Rate (95% C.I.) No Intervention 36.2 Clinician Training64.7 (53.1–74.8) Meta-analysis (2008): Effectiveness of clinician training on rates of providing treatment (“Assist”) (n = 2 studies) a Intervention Estimated Rate (95% C.I.) No Intervention 58.8 Training and charting 75.2 (72.7–77.6) Meta-analysis (2008): Effectiveness of clinician training combined with charting on asking about smoking status (“Ask”) (n = 3 studies) a Meta-analysis (2008): Effectiveness of and estimated abstinence rates for clinician training (n = 2 studies) a

49. Systems Evidence Intervention Estimated Abstinence Rate (95% C.I.) No Intervention11.4 Training and charting41.4 (34.4–48.8) a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis. Intervention Estimated Rate (95% C.I.) No Intervention 8.7 Training and charting 28.6 (24.3–33.4) Meta-analysis (2008): Effectiveness of training combined with charting on providing materials (“Assist”) (n = 2 studies) a Intervention Estimated Rate (95% C.I.) No Intervention 6.7 Training and charting 16.3 (11.8– 22.1) Meta-analysis (2008): Effectiveness of training combined with charting on arranging for follow-up (“Arrange”) (n = 2 studies) a Meta-analysis (2008): Effectiveness of training combined with charting on setting a quit date (“Assist”) (n = 2 studies) a

50. Providing Treatment as a Covered Benefit a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis. Treatment Estimated Quit Attempt Rate (95% C.I.) Individuals with no covered benefit30.5 Individuals with the Benefit36.2 (32.3–40.2) Meta-analysis (2008): Estimated rates of quit attempts for individuals who received tobacco use interventions as a covered health insurance benefit (n = 3 studies) a

51. Treatment in Children & Adolescents Meta-analysis (2008): Effectiveness of and estimated abstinence rates for counseling interventions with adolescent smokers (n = 7 studies) a a Go to www.surgeongeneral.gov/tobacco/gdlnrefs.htm for the articles used in this meta-analysis. Adolescent Smokers Estimated Abstinence Rate (95% C.I.) Usual care6.7 Counseling11.6 (7.5–17.5)

52. 5 As A1. Ask—Systematically identify all tobacco users at every visit A2. Advise—Strongly urge all tobacco users to quit A3. Assess—Determine willingness to make a quit attempt A4. Assist—Aid the patient in quitting (provide counseling and medication) A5. Arrange—Ensure follow-up contact Treating Tobacco Use and Dependence: 2008 Update” Clinical Guideline

53. Elements of Counseling Problem solving/ skills training Recognize danger situations – Develop coping skills- Identify and practice coping Provide basic information Supportive treatment Encourage the patient in the quit Attempt Communicate caring and concern. Encourage the patient to talk about the quitting process. Treating Tobacco Use and Dependence: 2008 Update” Clinical Guideline