‘SMOKE GETS IN YOUR EYES’: Optometrists talking with patients about tobacco

Marlee M. Spafford, OD, MSc, PhD, FAAO

Personal Disclosure For this lecture, I have:  developed the course material independently

 developed the course material without commercial interests  no personal conflicts of interest  no financial relationship with a commercial interest

Course Outline  Tobacco Use:  In Canada (and beyond) 

Among special populations

 Types  Dependence  Health impacts

 Optometrists & Tobacco Prevention/Cessation/Protection:  Role in providing tobacco education 

Approaches to smoking prevention/cessation/protection with patients



Services and resources to assist patients with quitting

http://www.globaltimes.cn/business/industries/2009-08/456424.html

What some have said… What the tobacco industry wants people to believe is that tobacco is nothing but a natural product grown in the ground, ripped out, stuffed into a piece of paper and served up. It’s not. It’s a meticulously engineered product. The purpose behind a cigarette is to deliver nicotine—an addictive drug. Jeffrey Wigand, PhD Former VP (R&D), Brown & Williamson

http://www.bubblews.com/news/213932-reasons-why-people-smoke http://cdn.greenoptimistic.com/wp-content/uploads/2010/01/tobacco_plant-300x300.gif

Tobacco Messaging: The 50s

http://www.smokernewsworld.com/wp-content/uploads/2011/05/Lucky-Strike.jpg http://171.67.24.121/tobacco_web/images/tobacco_ads/keeps_you_slim/sweet/large/sweet_1.jpg http://skydancingblog.com/2012/12/

Tobacco use in Canada  Current population: 35.3 million

 ≥15-yr-olds, who smoke:  2011: 17%

2011

 1999: 25%  1965: 50%

17% Never Former 26%

57% Current

Worldwide Females

Males

http://en.wikipedia.org/wiki/Prevalence_of_tobacco_consumption

Special Populations: Canadian Youth  Average age of 1st cigarette: 10 yr: Assess tobacco use every visit http://www.tobacco-news.net/youth-smoking-rates-now-stalled/

Special Populations: Pregnant Women  20-30% use tobacco during pregnancy  ≤24 yrs vs. >24 yrs 3:1  Impacts: Women  Spontaneous abortions  Placental abruption  Stillbirths  Premature births  Impacts: Off-spring  Low birth-weight  Sudden infant death syndrome (SIDS)  Cleft lip/palate  Cognitive, emotional, behavioral problems  Strabismus http://www.freshne.com/Programmes/helping-smokers-to-quit/smoking-and-pregnancy

Special Populations: Aboriginal Populations  Uses:  Traditional & medicinal (sacred pipes)  Recreational  Prevalence  On-reserve 1st Nations people:

 59% smoke  52% start between 13-16 yrs  Inuit people, in the north  58% smoke  46% of Inuit start at ≤14 yrs

http://www.northernstar.com.au/news/advertising-campaign-helps-aboriginal-smokers/811684/

What some have said… Cigarettes may have a higher dependence potential than heroin, cocaine, alcohol, and marijuana; that is, it is more difficult for some people to stop using cigarettes than any of these other substances. (Ferrence et al., 2000, p. 445) Nicotine and Public Health. Washington, DC American Public Health Association

http://amog.com/health/joy-smoking/

Tobacco Math  Cigarette smoke contains >4,000 chemicals  >70 cause, initiate or promote cancer  tar, ammonia, CO, oxides of nitrogen & benzopyrene

 ~15 puffs/cigarette  20 cigarettes/day = 300 drug doses/day (>100,000 doses/yr)

Nicotine (alkaloid)

http://www.cbc.ca/news/canada/story/2012/05/09/smoking-rates-canadians.html

More Tobacco Math Cigarettes

Ontario Costs

Sizes: 70, 84, 100 & 120 mm Packages: 20-25 cigarettes

~ $10-13 (~$4,200/yr)

Cartons: 200 cigarettes

~$80 (~$3,300/yr)

In 10 yrs…

http://www.autospeedmarket.com/2012/05/mini-jcw-gets-new-engine.html

Tobacco-Related Deaths in Canada >37,000 deaths/year 8-yr shorter lifespan

>1,000 deaths/year #2 cause of lung cancer

http://www.cbc.ca/news/health/story/2011/07/29/f-smoking-laws-timeline.html http://www.cbc.ca/news/health/story/2011/07/29/f-smoking-laws-timeline.html

Tobacco-Related Deaths in Canada 1 in 5: smoking

1 in 2 smoking deaths: 44 to 50-yrs-old

http://www.crwflags.com/fotw/flags/ca-on-ws.html

What some have said… Each year, smoking kills more people than AIDS, alcohol, drug abuse, car crashes, murders, suicides, and fires - combined. Tobacco Information and Prevention Source, 2000 Centers for Disease Control and Prevention

http://www.reduxmedia.com/advertisers-blog/item/40-i-take-it-back-anti-smoking-ads-work-after-all-my-bad

Smoke Tobacco: 99% of Canadians #1

Cigarettes (worldwide)

Cigars (Central America)

Pipes (N. Africa, Mediterranean & Asia)

Bidis (S. East Asia)

Kreteks (Indonesia)

Smokeless Tobacco: 1% of Canadians

Snuff (nose or lower gum & cheek)

Snus (upper gum & lip)

Chewing tobacco (loose, plugs & bricks) (gum & lower cheek)

Dissolvable Tobacco (lozenges)

e-cigarretes (electronic)

What some have said…

http://snus-news.blogspot.ca/2009_09_20_archive.html

Addiction (Centre for Addiction & Mental Health) …a primary, chronic, neurobiologic disease with genetic, psychosocial and environmental factors… characterized by …the 4 Cs:  Craving  Control loss regarding use (amount or frequency)

 Compulsion to use  Continued use despite consequences

http://www.cbc.ca/books/2013/02/coping-with-addiction-in-the-family.html

Elements of Tobacco Addiction Chemical Element  100-400 drug doses/day

Routine Element  Relationship with cigarette  2-hr half life  Part of social activities  Increasing drug needed/time  Relaxation strategy  Something in hand

http://cp.c-ij.com/en/contents/2028/10208/

Nicotine: Short-term Effects  Effects are fasted through inhalation (with shorter duration)  Blood to brain 60 min (0 pts)  How many cigarettes do you smoke/day?  > 30  21-30  11-20  ≤ 10

(3 pts) (2 pts) (1 pts) (0 pts)

HSI - Nicotine Dependence Level

0-2 pts: Low 3-4 pts: Moderate 5-6 pts: High

Can you go > 4hrs without smoking?

Nicotine: Long-term (Review of Systems) System

Impact

Constitutional

Anything’s possible…

Eyes

AMD; cataract; OSD; TAO; NAAION; CRVO/BRVO; uveitis

ENT & Mouth

Periodontitis; tooth stains; cancer (mouth; larynx; pharynx)

Cardiovascular

HT; atherosclerosis; CAD (MI, CVA); CHF; PAD

Respiratory

Lung cancer (SCLC); COPD; respiratory infections

Gastrointestinal

Ulcers; cancer (esophageal, stomach, pancreas, bowel)

Genitourinary

Infertility; impotence; cervical, kidney, bladder cancer; LBW

Musculoskeletal

Osteoporosis; joints/bones (more injuries; slower healing)

Integumentary

Premature aging; psoriasis; SCC

Nicotine: Long-term (Review of Systems) System

Impact

Neurologic

Neurotransmitter imbalances (

Psychiatric

Addiction

Endocrine

Type 2 DM; Graves; osteoporosis; infertility

Hematologic/Lymphatic

Clotting; leukemia (AML)

Allergic/Immunologic

dopamine;

immunity

http://www.healthyhaywood.org/events/tatu.html

GABA)

Eye Diseases associated with Smoking Disease

AMD

Sub-Type Dry Wet

Cataract

Nuclear PSC

TAO

Thyroid-associated ophthalmopathy

Uveitis (with CME)

Infectious Inflammatory

Optic neuropathy

NAAION Toxic neuropathy

Ocular Surface Disease Tear film (lipid) Conjunctivitis/Keratoconjunctivitis http://www.learningradiology.com/caseofweek/caseoftheweekpix2/cow154lg.jpg

What some have said…

http://www.bubblews.com/news/177020-dangers-of-secondhand-smoke

Nicotine Effects: Smoker Knowledge Lung cancer COPD Heart disease Stroke

>90% >70% >80% >70%

Blindness

62%* Australia 18% UK 16% Canada 10% US

* Pre-2007: 49%

(2007-11)

Canada, UK, US, Australia

Canada: Graphic Warning Label Blindness message 1st introduced 2012

http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/legislation/label-etiquette/index-eng.php#warnings

Nicotine Cessation: Short-term Time

+ Changes

20 min

BP, pulse, body temperature normalize

8 hrs

nicotine blood levels decrease ~94% O2 & CO levels normalize

12 hrs 24 hrs

- Changes

Anxieties peaks

48 hrs

Taste & smell returning

Anger peaks

72 hrs

Body nicotine free

Cravings peaks

Nicotine Cessation: Longer-term Time

+ Changes

2-4 wks

Withdrawal Sxs ended

3-12 wks

MI risk lung function chronic cough insulin resistance MI & CVA risk 50%

1 yr

5-15 yrs

CVA risk of non-smoker Lung cancer risk 50-70%

- Changes

5lb weight gain

Quit Strategies  Individual & group counseling

 Self-help materials  Brochures, pamphlets, posters  Phone, online, & messaging program referrals  Smokers Helpline  Nicotine Replacement Therapy (NRT)  Non-nicotine oral medications  Other  Hypnosis, laser, acupuncture http://www.ehow.com/about_5393337_smoking-cessation-programs.html

Quit Strategies  Nicotine Replacement Therapy (NRT) referrals  Transdermal patch: craving  Gum & lozenges:  Nasal sprays & inhalers: Flex dosage; familiar routine  Sublingual tablets:

Potential Irony: Resisting drugs to stop smoking when cigarettes contain drugs

http://www.telegraph.co.uk/health/healthnews/9002252/Nicotine-patches-no-better-than-will-power-to-quit-smoking.html

Some NRT Facts: 2x Quit Rate  Safer than smoking  More effective for higher dependence  Higher dose more effective (4mg vs. 2mg)  Forms equally effective ~2x (at same dosage)  Safe for:  Combining forms  Mild/moderate CVD  ≥12-yr-olds  Pregnancy  Side-effects:  Throat/skin irritation; GI upset; sleep disturbance http://theconversation.com/nicotine-replacement-therapy-isnt-all-its-cracked-up-to-be-12153

Non-nicotine Oral Replacements  Affect brain chemicals via nicotine receptors  Bupropion SR (Sustained Release)  Zyban®; Wellbutrin®  1st use: anti-depressant  Side effects (seizures, allergic reactions)

 Varenicline tartrate  Champix™ (Canada); Chantix™ (U.S.)  Side effects (CVD; depressive disorders; schizophrenia)

http://colinmendelsohn.com.au/news/fda-safety-report-champix-reassuring/

Other Smoking Cessation Therapies  Therapies that may work for some but…

not supported by evidence  Hypnosis  Laser therapy

 Acupuncture

http://www.smh.com.au/news/national/laser-smoking-cure-latest-snake-oil-expert/2008/03/09/1204998283775.html http://www.democraticunderground.com/discuss/duboard.php?az=view_all&address=439x1082603

Optometrists: Tobacco prevention, protection & cessation (TPPC)

http://fn.bmjjournals.com/content/82/3/F233.abstract

Barriers for Optometrists: TPPC  2009 and 2011 Canadian optometry studies:  Too busy  Not paid for service  Lack education (re: communication & cessation/prevention)  ‘Not my job’ (done by others)  Outside scope of practice

But…

http://www.mrcophth.com/cataract/cataract.html

Smoking Cessation Research  Quit attempt success:  Unassisted: 3-5%  Health practitioner assisted: 20%

 All health practitioners can assist with quitting

 Most helpful images:  Graphic images

 Most helpful messages:  Gain-framed

http://www.imedicalapps.com/2012/02/mobile-phone-smoking-cessation-interventions-us-task-force/

Graphic Warning Label Research  Most effective cigarette package warnings:  Large pictorial health warnings  Favour educational text over testimonial text  Opposite for lower socioeconomic audience

 Elicit strong emotional reactions  Fear  Disgust

http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/legislation/label-etiquette/index-eng.php#warnings

Message Framing Research: Smoking Gain-Framed

Loss-Framed

You will live 10 years longer if…

You will die 10 years sooner if…

http://chociceandchips.co.uk/do-not-park-here-or-else/

 What?  Stop smoking  Change linked activities  Change relationships  Why?  Best aspects of smoking

How important?

Making change is hard to do

How confident?

http://www.edrugstore.md/articles/smoking-cessation/ http://www.healthtipsexpress.com/Health-Tips/Healthy-Living/Quit-Smoking-Tips-For-The-First-Week-Of-Smoking-Cessation.aspx

The 5 As of Tobacco Intervention  ASK  Do you currently use tobacco? No - do others around you?

 ADVISE  Advise of importance of quitting

 ASSESS  Determine readiness - Are you thinking about quitting?  No (Pre-contemplate); Yes (contemplate; preparation; action)

 ASSIST  Provide self-help materials or refer to cessation support  Smoker’s Helpline; Health Region Addiction Counselor

 ARRANGE  Follow-up with reinforcement & trouble-shooting (e.g., 1 wk)

ASK: Do you currently use tobacco? No  Congrats!  Reinforce decision

Does anyone smoke around you/your family?

Yes Advise & Assist:  Encourage smoking outside buildings/cars  Give resources

No  Reinforce reduced risks  AMD, cataract, stroke, etc.,

ASK: Do you currently use tobacco? Yes Advise: My most important advise: Quit. And I can help

Assess: Are you thinking about quitting?

Yes Determine Quit State: Action: Now Preparation: Next 30 d Contemplation: Next 6 m

No Pre-contemplation: Not ready

Assess: Are you thinking of quitting? Yes

No

Assess Dependence

Assist

HSI; Onset/Timing; Quit Hx

Offer info/resources

Assist Provide self-help materials Refer to cessation/support resources

Arrange (1 wk follow-up) Reinforce & troubleshoot Additional support

(Risks, cessation strategies)

Harm reduction Provide motivation

Tobacco Communication  Overall:  Be free of judgment  Start young: >10 yrs  Aim for protection, prevention, and cessation  Interview:  Assess exposure and use, every visit  Determine chronology:  Onset; type; associated activities; appealing aspects

 Calculate HSI (# cigarettes/day; 1st of day)

http://www.videoconverterfactory.com/tips/convert-video-to-vob.html

Tobacco Communication  Counseling:  Adopt 5 As strategy  Educate about eye & systemic effects  Employ gain-framed messages (patients value sight)  Advise 3As when quitting  Avoid: situations known to stress  Alter: realistic expectations  Acceptance: can only control self

 Free smoking cessation brochures &/or posters for

optometrists can be ordered at:  http://www.propel.uwaterloo.ca/optometry/ http://www.videoconverterfactory.com/tips/convert-video-to-vob.html