Good Morning Welcome to DAY 3 Were

Good Morning! Welcome to DAY 3

Were you able to complete the Values Check #2 exercise last night? a. Yes b. No c. I meant to, but was busy doing other things. 2

Values Exercise # 2 Choose the answer closest to yours : “Women smoke because _______”? a. b. c. d. e. 4 They think it’s feminine They want to control their weight They love to smoke It helps their stress levels Other

Values Exercise # 2 Choose the answer closest to yours : “Cardiovascular disease is caused by _____”? a. b. c. d. e. 5 Lack of exercise Genetics Smoking- no matter how much Pollution Other

Specific Populations and Tobacco Use

Why Focus on Specific Populations? • • • 8 Mental health issues Medical issues Addictions Gambling disorders People who are homeless or underhoused Older Adults • • LGBTTTIQQ persons Youth Pregnant women Incarcerated individuals Military recruits Ethno-cultural groups Aboriginal Persons

I have, or my organization has, cessation services available for specific populations. a. We are structured to be accessible to a range of populations. b. We are accessible to a few specific populations on an asneeded basis. c. I am not sure what is available. d. Limited cessation services are available for specific populations. 9

Small Group Discussion • • • 10 At your tables, please share your experiences providing cessation services to specific populations…. . What are some key considerations? What questions to do you have?

Introduction • • • Historical perspective Barriers to tobacco control Associations: complex Understanding remains incomplete Association is: – robust, reproducible, and clinically significant 11 1. 2. 3. 4. 5. Joseph et al. , 2004 Masterson & O’Shea, 1984 Zuckermann & Kuhlman, 2000 Brandt & Gardner, 2000 Els, Kunyk, 2008.

In which type of disorder would we see the highest rate of smoking prevalence? a. b. c. d. e. 12 Anxiety disorder Major depression Bi-polar disorder Schizophrenia Personality disorders

Prevalence of Smoking in Psychiatric & Substance Use Disorders Psychiatric disorders Substance use disorders Non-psychiatric/substance use disorders Smoking prevalence (%) 100 80 60 40 20 co ho Co l ca in e O pi oi d G en U po S p Al SD PT CD O PD DD M D BP SZ 0 Clinical group 13 SZ, schizophrenia; BPD, bipolar disorder; MDD, major depressive disorder; PD, panic disorder; OCD, obsessive-compulsive disorder; PTSD, post-traumatic stress disorder Kalman et al (2005) Am J Addict 14(2): 106 -123

Youth & Smoking: There is no significant difference between the number of teenage males and teenage females who smoke a. True b. False – Significantly more teenage females smoke c. False – Significantly more teenage males smoke 14

Youth and Smoking • Smoking youth aged 15 -19: 14% – Lowest rate recorded since Health Canada first (CTUMS, 2010 Wave 1) – – 15 began recording prevalence → 13% males, 14% females reported smoking 8% reporting daily smoking 6% occasional smoking Average 11. 6 cigarettes per day 25% purchased discount-brand cigarettes, 19% from First Nations' reserve, 5% that may have been smuggled (CTUMS, 2009 Annual Results) CTUMS, 2010, Wave 1 Results – February-June

Young Adult Male Smoking: 20 -24 Years of Age • 24. 3% are Current Smokers § has consumed 100 cigarettes in his/her life and has smoked within the last 30 days • 16. 5% are Daily Smokers § has consumed 100 cigarettes in his/her life and has smoked daily for the last 30 days • 68. 7% are Never Smokers § Someone who has not smoked in the last 30 days • 75. 7% are Non Smokers § Someone who has never smoked 100 cigarettes or more in his life 16 Canadian Tobacco Use Monitoring Survey, 2009

Other Associations in Youth • • • 17 Sexual and physical abuse/trauma Other psychiatric disorders • Eating disorders • Depressive disorders • Suicide attempts • ADHD Impoverished and dysfunctional households 1. De Von Figueroa-Moseley et al. , 2004 2. Nichols & Harlow, 2004 3. Menutt et al. , 2002 4. Dube et al. , 2003 5. Potter et al. , 2004 6. Cornelius et al. , 2001

Tobacco and Mental Illness • 18 Mental illnesses associated with higher rates: → Schizophrenia → Major mood disorders • Depression • Mania / Bipolar illness → Alcohol use → Other substance-related disorders → Anxiety disorders → Personality disorders 1. Hughes et al. , 1986 2. Grant et al. , 2004 3. Breslau et al. , 1991, 1994 4. Lasser et al. , 2000

Smoking and Schizophrenia • • Prevalence rates of 72. 5% (up to 90%) More likely to smoke and less likely to quit Biological variables Quitting smoking may impact on symptoms of schizophrenia: Positive symptoms → Negative symptoms → Cognitive symptoms → 19 Baker et al. , (2010). Smoking and Schizophrenia: Treatment approaches within primary care. Primary Psychiatry, 17(1): 4954

Psychotropic Drug Interactions Impacted: Impacted • Clozapine • Olanzapine • Haloperidol • Chlorpromazine • Caffeine 20 De. Leon, J. (2004). Psychiatric Serv. 55: 491 -493. Not Impacted: • Risperidone • Ziprasidone • Aripiprazole • Quetiapine • Bupropion

Psychotropic Drug Interaction Example: Clozapine • • • Smoking cessation leads to increased clozapine plasma levels of up to 50%, which could lead to adverse events and toxicity (1) – Increase could persist to up to 4 weeks Plasma levels should be monitored frequently (2) Dose may require lowering of 30 -40% of original dose (3) • Warning signs that medication dose needs adjusting (3) – Worsening psychiatric symptoms – Excessive fatigue or sleepiness – Extrapyrimidal effects (i. e. tremor, slurred speech, dystonia) – Seizures 21 1. Cormac et al. (2010) 2. De Leon (2004) 3. Lowe & Ackman (2010)

Treatment Implications • • 22 1. 2. 3. 4. NRT Bupropion Atypical antipsychotics Varenicline Addington, et al. , 1998 Chou et al. , 2004 George at al, 2000 Evins et al. , 2005

Prevalence of Smoking: Patients with Depression Depressed patients 56% 44% Current smokers 23 1. Farrell et al (2003) Int Rev Psychiatry 15(1 -2): 43 -49; 2. Mackay et al (2006) The Tobacco Atlas 2 nd ed General population 26% 74% Nonsmokers

Mood Disorders • 24 1. Thorsteinsson et al. , 2001 2. Hayford et al. , 1999 3. Chengappa et al. , 2001 Treatment implications: – NRT – Anti-depressants – Varenicline – Bupropion

Smoking and Depression Tobacco smoke exposure is associated with a marked reduction in brain MAO A, which suggests that MAO A inhibition needs to be considered as a potential contributing variable in the high rate of smoking in depression. 25 Fowler J. , et al (1996) Proc Natl Acad Sci USA 93: 14065 -14069

Monoamine Oxidase (MAO) Enzyme Inhibition in Smokers This study showed that smokers have significantly reduced MAO B in peripheral organs, particularly in the heart, lungs, and kidneys, when compared with non-smokers. 26 Fowler et al (2003) Proc Natl Acad Sci USA 100(20): 11600 -11605

Smoking & Suicide Risk P<. 001 5 4. 3 Relative riska 4 2. 5 3 2 1 0 1. 4 1. 0 Never smokers Exsmokers 1 -14 (n=1333) 15 (n=2241) Cigarettes/day: current smokers 27 Miller et al (2000) Am J Public Health 90(5): 768 -773

Safety Considerations • History of Depression: → → → 28 75% reported depressed mood < 1/52 Need aggressive monitoring and treatment Vigilance for up to 6 months after quitting Beck Depression Inventory, consultation with psychiatrist Depression is a predictor of relapse

Anxiety • Rates of smoking 2 x greater then general population → → → • Nicotine is anxiogenic → 29 Range 19. 2 – 56% Panic Disorder 40% PTSD 63% Lower anxiety within 2 weeks of quitting 1. Amering et al. , 1999 2. Valenca et al. , 2001 3. Herzbert et al. , 2001 4. Hughes et. al, 1996

When is the “best” time for a person with substance use problems to quit smoking? a. Before they enter addiction treatment b. Concurrently with their other treatment c. After they have been treated 30

Concurrent Treatment of Tobacco and Other Substances • • 25% of clients in addiction treatment want to quit all substances, many are willing to explore the issue 1 Relapse rates are lower if all substances are addressed concurrently – In a study of a substance use treatment program where smoking was not addressed about 12% of the clients either started to smoke or relapsed to smoking 2 • Need to address therapists’ misconceptions of concurrent substance use treatment – Concurrent tobacco dependence treatment does not jeopardize alcohol and non-nicotine drug outcomes 3 31 Schroeder & Morris, 2010 Kohn et al. , 2003 Kalman et al. , 2010

Concurrent Treatment: A Standardof-Care and a Duty-of-Practice “A court could have sufficient basis to find that the failure to adequately treat the main cause of preventable disease and death qualifies as a violation of the legal duty that healthcare practitioners owe to patients habituated to tobacco use and dependence…” (Torrijos & Glantz, 2006) 32

Alcohol and Tobacco • • 33 Strong correlation Dose-dependent Mortality rates increased Possible gateway hypothesis? Colby, 1994 Selby & Els, 2003

Incarcerated Individuals • • 34 Extremely high smoking prevalence of up to 91% reported (2) and nearly ½ have other substance abuse and mental health issues (3) Limited treatment or programs available – 1 RCT to date; outcome indicates a combination of CBT + pharmacotherapy is an effective method for incarcerated individuals (quit rate of 14% at 6 -month follow-up) (1) Forced abstinence through bans leads to short-term cessation only – 75 -100% smoking relapse rate of incarcerated individuals upon release (3) Smoking bans will contribute to a healthier environment, better air quality; but should be coupled with cessation interventions for sustained quit 1. Cropsley et al. (2008) 2. Donahue (2009) 3. Diamond et al. (2009)

People Who are homeless or underhoused • • • 35 1. 2. 3. 4. Difficult research population 75 -85 % tobacco prevalence Master Settlement Agreement revealed industry marketing No peer-reviewed smoking cessation programs Interest likely exists in quitting Connor et al. , 2002 Folsom & Jeste 2002 Martens, 2001 Arnsten et al. , 2004

Gambling Disorders • • 36 Strong positive association 43 – 66% tobacco prevalence Limited empirical evidence Systemic approaches, e. g. bans, have little impact on monetary profits 1. Potenza et al. , 2004 2. Petry & Oncken, 2002 3. Glantz & Wilson-Loots, 2003

Are you aware of the differences between non-traditional and traditional tobacco use in First Nations? a. b. c. 37 Yes, I am sensitive to this in my practice. Yes but I don’t know how to approach it with my Aboriginal clients. No, this is something I need more information about.

Indigenous Populations • • • 38 What is traditional use of tobacco? Smoking rates higher Lower age groups overrepresented 2004 Baseline Study Among First Nations On-reserve and Inuit in the North, Environics Research Group

Smoking Among First Nations (living on-reserve) 39 Pinto A. , Manson HE. (March 10, 2011). Tobacco related disparities and equity. Presented at the Smoke-Free Ontario Knowledge Exchange Forum, Toronto, Ontario

Smoking Among First Nations (living on-reserve) 40 Source: 2002/03 First Nations Regional Longitudinal Health Survey, as report in RHS Quick Facts, available from: http: //www. fnigc. ca/sites/default/files/ENpdf/RHS_2002/rhs 2002 -03 quickfacts. pdf

Factors to Consider • • • 41 Diversity among Indigenous Populations Access to healthcare resources Traditional approaches to healing/recovery Geographical location Intergenerational trauma Economic incentives from tobacco sales/production in some communities

LGBTTTIQ* Population • • • 42 1. 2. 3. 4. 5. Limited studies & almost no Canadian data Demographics vary & methodological flaws Reasons for high smoking rates? Treatment on small scale with limited evidence L = Lesbian; G = Gay; B = Bisexual; T= Transsexual; T = Transgendered; T = Two-Spirited; I = Intersex; Q = Queer/Questioning Greenwood et al. , 2005 Stevens et al. , 2004 Ryan et al. , 2001 Tang et al. , 2004 Mays & Cochran, 2001

Statistics in LGBTTTIQ Community • • 43 Some US studies estimate 48% of LGBTTTIQ population smoke Association between smoking and bacterial pneumonia, hairy leukoplakia, oral candidiasis and AIDS-related dementia Presentation by Janice Forsythe. Cypress Consulting, Ottawa (Source: Healthy People 2010: Lesbian, Gay, Bisexual and Transgender Health. Chapter on Tobacco Use. )

Women and Pregnancy Why do women smoke? • • • Controlling weight / fear of weight gain Addiction Concurrent mental health problems Coping with emotions, stress “Fitting in” Fashion, style and marketing Risks decrease with quitting: • • • 44 Vaginal bleeding, premature delivery, abruptio placenta and placenta previa Spontaneous abortion Perinatal mortality Better chance of having a healthier birth weight Easier time with breastfeeding

Evidence-Based Interventions • • • 45 Maximum quit rate about 20% despite best intervention Self-help materials tend to have good quit rates Telephone quit lines are a cost-effective way to reach smokers with some efficacy • Counselling doubled abstinence rates • Seven quit-line counselling sessions • Brief treatment often no different than intensive counselling • Consider NRT if behavioural interventions do not work 1. Zhu, 2002 2. www. Pregnets. org 3. Ershoff, 1999

Key Message • 46 Focus on the woman’s health

Focus on Special Populations: Implications for Tobacco Control • • • 47 High prevalence & high risk Smoking impacts disproportionately Rates overrepresented in subgroups Mentally ill youth at greater risk of uptake Often not addressed by mainstream tobacco control approaches

Contingency Management • • 48 Incentive based programming Despite demonstrated efficacy in addictions limited use in smoking cessation Barriers include people’s attitude towards incentives in treatment. Ledgerwood, DM. (2008) Contingency management for smoking cessation: where do we go from here. Current Drug Abuse Reviews 1(3): 340 -9

Suggestions for Tobacco Control • • 49 Identify high-risk youth Identify hard-to-reach populations Offer counselling/medications in criminal justice settings Parity of coverage

Conclusions • • • 50 Evidence emerging Supporting cessation is crucial for health promotion Needed: – More comprehensive and tailored supports – Further research – Advocacy

Case Discussion • • • 51 Kevin is a 45 -year-old male who is living with schizophrenia who reports regular smoking since age 14. He is on clozapine, which he takes regularly as prescribed, and was referred to the tobacco clinic by his community support worker. His support worker noticed that even though Kevin smokes contraband cigarettes, the financial impact of his smoking affects his overall quality of life and ability to “make ends meet” between receiving government disability cheques. Kevin states that he smokes approximately 76 cigarettes per day, and says that he has been wanting to quit for a long time. His CO levels are 25 ppm. In his assessment, Kevin states, “I heard you people can make quitting easy – that’s what I need. This is it! I am walking out of here a non-smoker. ”

Discussion Questions 1. 2. 3. 4. 52 In addition to the financial impact and # of cigarettes per day, what other areas would you want to assess (and address) with respect to Kevin’s tobacco use? What do you think of Kevin’s decision to quit immediately? How would you respond? If you were recommending a nicotine patch, what level would you recommend he start with? What psychosocial intervention(s) might be helpful in this case?

Break Time: 15 Minutes 53

Questions ? 54

Lunch! 30 Minutes

Tobacco Industry Denormalization Michael Perley: Director, Ontario Campaign for Action on Tobacco Based on research and presentations from the Non-Smokers’ Rights Association

What is Tobacco Industry Denormalization (TID)? • • • Telling the public the truth about the tobacco industry’s role in the perpetuation of the tobacco epidemic in appropriate language Show the public why the tobacco industry falls outside the boundaries of normal business behaviour Reverse the industry’s decades-long effort to normalize itself 57 Slide from Michael Perley, Ontario Campaign for Action on Tobacco

What Tobacco Industry Denormalization Is Not • Messages or programs that do not refer to the tobacco industry and its role in the epidemic, such as those referring to “smoking” or “smokers” as their main subjects 58 Slide from Michael Perley, Ontario Campaign for Action on Tobacco

From this list, select one statement with which you agree the most strongly. a. b. c. d. e. 59 Cigarettes are too dangerous to be sold at all; The tobacco industry rarely/never tells the truth about health effects of smoking; The tobacco industry is mostly/completely responsible for health problems smokers have because of their smoking; The Ontario government should sue tobacco companies for health care costs caused by tobacco products; The tobacco industry should be fined by government for money earned from tobacco sales to minors.

Tobacco Industry Behaviour 1950 s-60 s • First linkage of tobacco-lung cancer in medical literature; industry PR firm suggests counterattack against scientists to reduce public worry • The TIRC plan: spend massively to block scientists and public health officials from warning people of potential health hazards • Industry researchers find numerous carcinogens in tobacco smoke: research hidden 60 Slide from Michael Perley, Ontario Campaign for Action on Tobacco

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Tobacco Industry Behaviour (2) • In 1962, the Chairman of British American Tobacco asked: “If we make safer brands, how to justify continuing the sale of other brands? It would be admitting that some of (our) products already on the market might be harmful. ” (A Mc. Cormick, British American Tobacco, 1962) 1970 s • “Safer” cigarettes designed and tested, but companies could no longer afford to offer safer cigarettes to smokers 62 Slide from Michael Perley, Ontario Campaign for Action on Tobacco

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Tobacco Industry Behaviour (3) The 1977 Bath Summit (BAT, PM, ITL, RBH, RJR): agreed to deny known health effects of tobacco and conceal known toxicity of tar, nicotine and other chemicals in tobacco 1980 s • Company scientific labs shut down, medical findings hidden or destroyed • 64 Slide from Michael Perley, Ontario Campaign for Action on Tobacco

Industry Tactics Lies and Deception Youth Programs Corporate “Philanthropy” Junk Science Advocacy How the industry normalizes tobacco Third Parties Hollywood 65 Slide from Michael Perley, Ontario Campaign for Action on Tobacco Advertising Sponsorship

What the Industry Really Thinks “In order to make further inroads into the younger segment, we must continue to project an image that is consistent with the needs and values of today’s younger smokers. ” (RJR, 1989) “Although the key 15 -19 age group is a must for RBH there are other bigger volume groups that we cannot ignore. ” (RBH, 1997) 66 Slide from Michael Perley, Ontario Campaign for Action on Tobacco

What the Industry Really Does “The 1988 tracking study is the second of a planned series of research studies into the lifestyles and value systems of young men and women in the 13 -24 age range. ” (ITL, 1988) 67 Slide from Michael Perley, Ontario Campaign for Action on Tobacco

Operation ID: The Tobacco Industry’s Youth-Friendly Face 68

Concerned About Children Smoking? We Are, Too! 69

Three on Three Hockey 70

Lanny Mc. Donald 71

Guy Carbonneau 72

In 2002, the Ontario Medical Association drew the following conclusions about Operation ID: • • • 73 “Tobacco industry documents make clear that their youth access programs have little or nothing to do with reducing youth smoking”. “The failure of these programs is inevitable because they are voluntary”. “Youth access and educational programs target the wrong outcome, access, rather than consumption”. “More Smoke and Mirrors: Tobacco Industry-Sponsored Youth Prevention Programs in the Context of Comprehensive Tobacco Control Programs in Canada”, February 2002

Key Industry Tactics/Messages A risky – but legal – product • “We don’t market to children” • Light and mild • Questionable research (attacks on the risks of second-hand smoke) • Cigarette smuggling uncontrollable • Rights and freedoms: the “nanny state” • Economic fallout • Front groups (mychoice. ca [now defunded by ITL], FAAC, hospitality) 74 Slide from Michael Perley, Ontario Campaign for Action on Tobacco

Industry Tactics: Advertising and Promotion • • • Power walls (banned in most provinces) Point-of-sale signage and displays (as above) Branding Movies Grey areas (bar promotions) 75 Slide from Michael Perley, Ontario Campaign for Action on Tobacco

Industry Sponsored Tobacco Promotions 76 http: //www. tobaccofreekids. org/ adgallery/display. php 3? ID=204

77 Benson and Hedges Cigarette Girls for a 2003 promotion aimed at Young Adults

The Industry’s Behaviour Today 78

The Industry’s Behaviour Today 79

The Industry’s Behaviour Today Post Bill C-32 and Ontario Bill 124, cigarillos have simply become small cigars without filters, but with the same attractive flavours such as cherry, strawberry and peach. 80

Flavoured Tobacco Products 81

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Tobacco Industry Denormalization Strategies Objective: Expose the Industry • Combat myths about tobacco products • Draw attention to nature, extent, impact of tobacco industry advertising/promotional activities • Draw attention to role of other organizations in supporting promotion and sale of tobacco 83 Slide from Michael Perley, Ontario Campaign for Action on Tobacco

Tobacco Industry Denormalization Strategies (2) • • • Paid media (CA, Mass. , other US states) Earned media (NSRA exposure of St. Michael’s University acceptance of ITL corporate ethics funding; CCS/NSRA protest chief tobacco lobbyist’s presence on WCH board; U of Sask. SU rejects $250, 000 grant from ITL) Research/lobbying/advocacy 84 Slide from Michael Perley, Ontario Campaign for Action on Tobacco

Unsweetened Truth 85

Do You Have What it Takes…? 86

Smokenders 87

Smoking Dog 88

Demon Awards 89

Contraband

Contraband What does this word mean to you? With a partner, discuss this for a few minutes. 91

Are some cigarettes more harmful than others? A. No- all have the same level of danger to health, no matter where the cigarettes are manufactured B. Yes- unregulated cigarettes are more harmful C. Maybe- I need some more information to make a decision 92

The 1990 s Smuggling Crisis • Tobacco industry-driven: tax-free main-brand industry products exported to bonded warehouses in New York State, smuggled back into Ontario/Quebec • Result: Federal and several provincial governments cut tobacco taxes by 50% in 1994 • Impact: Up to 40, 000 excess deaths as a result of increased youth smoking (Health Canada draft) 93 Slide from Michael Perley, Ontario Campaign for Action on Tobacco

Smuggling/Contraband Today • The product: 200 -cigarette “baggies” manufactured on 4 -5 U. S. /Ontario/Quebec reserves (contrast: 190+ reserves in Ontario alone) • Involvement of non-FN organized crime elements: contraband tobacco trade funds smuggling of drugs/guns/people 94 Slide from Michael Perley, Ontario Campaign for Action on Tobacco

Smuggling/Contraband Today (2) • A problem for all communities: $8 -10/baggie cigarettes vs. $5070+ discount/main brands help lead to 1) FN community smoking rate of 59%; 2) flattening/reversal of non-FN prevalence declines • Sources: on-reserve smoke shacks (some southern Ontario/ Quebec reserves), off-reserve non-FN supply chains 95 Slide from Michael Perley, Ontario Campaign for Action on Tobacco

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Solutions • Nation-to-nation negotiations/trade and other economic agreements • Off-reserve enforcement esp. re: organized crime 99 Slide from Michael Perley, Ontario Campaign for Action on Tobacco

Ontario’s Bill 186 • • • 100 Tobacco leaf management system Fine cut tobacco marking system New fine structure Seizure “in plain view” Arrangements and agreements with First Nations

Questions? 101

Break Time: 15 Minutes 102

Harm Reduction

What is your perspective on harm reduction and tobacco use? a. There is no such thing – all tobacco use is harmful b. I can see that might be necessary with some populations c. I believe in using a harm reduction approach d. I’m not sure - I need more information 104

Discussion What is one thing you want to take away about harm reduction? 105

“ Don’t give up the ship in a storm because you cannot hold back the winds. You must not deliver strange and out of the way speeches to people with whom they will carry no weight because they are firmly persuaded the other way. Instead, by an indirect approach, you must strive and struggle as best you can to handle everything tactfully – and thus what you cannot turn to good, you must at least make as little bad as you can. ” 106 St. Thomas More 1478 -1535, Utopia, CWM, v. 4, pp. 99, 101 -(More, St. Thomas More 1478 -1535, Utopia, CWM, v. 4, Logan et al. 1995) pp. 99, 101 -(More, Logan et al. 1995)

Do you drive a car with anti-lock brakes? a. Yes b. No c. Do bikes count? 107

Which type of vehicle allows you to stop faster? a. Cars with anti-lock brakes b. Cars without anti-lock brakes c. No difference 108

Tobacco Harm Reduction TOTAL HARM Harmfulness Danger Intensity 109 Mac. Coun and Reuter 2001 Prevalence

Issue: The Precautionary Principle – Can science of nicotine help? • • The precautionary principle: – "When an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically. In this context the proponent of an activity, rather than the public, should bear the burden of proof. " A key issue in advocating a tobacco control harm reduction strategy involving the use of less harmful forms of nicotine delivery, is the evidence of safety of nicotine per se. 110 Wingspread statement

Most Harmful – least regulated Some Harm – some regulation 111 Least Harmful – most regulated

A Controversial Topic? • • • 112 Tobacco control has always taken a harm reduction perspective – Smoke free policies, taxation, etc. There is support for harm reduction – CAMH, OMA What do we mean by harm reduction?

http: //www. maricopa. gov/Public_Health/Community/Tobacco/ 113

General View on Harm Reduction • • • 114 Aims to reduce the adverse health, social, and economic consequences of drug use without requiring abstinence Abstinence is healthiest choice Focuses on the most immediate and achievable changes Public health alternative to the moral/criminal and disease models of drug use Non-judgmental, non-coercive

General Principles of Harm Reduction • • 115 End users should have a voice in the creation of programs and policies designed to serve them (client-centered care) Values patient autonomy and provider patience Culturally sensitive Although abstinence from tobacco is recommended, many smokers are unable or not ready to quit

Benefits of Harm Reduction Approach (1) Daily use Reduction Continuum • • • 116 Engages Increases confidence Changes behavioural patterns Abstinence

• • 117 “Quit or die” is irresponsible, unethical and unrealistic Millions are highly addicted and have low cessation rates Appears deeply rooted in some communities (I. e. : those with mental health issues, aboriginal) Creates a market incentive for ever-better products to replace cigarettes

Cautions against Harm Reduction • • • 118 Distraction from quitting – Need more resources devoted to quitting Premature admission of defeat Extra harm to people that would have otherwise quit completely Potential for young people to start with products they believe it to be safe Ex-smokers may use products as an option causing relapse

Benefits of intermittent quitting on reducing death 119 From Lung Health Study – 14. 5 year follow-up Slide from Paul Mc. Donald

Effective Harm Reduction Strategies • • • 120 Product regulation – warnings on packages, making cigarettes taste bad, anti-counterfeiting Changing nature of products containing nicotine – Low nitrosamine cigarettes only cut out 1 carcinogen Taxation - increasing the amount of taxes on cigarettes decreases consumption especially with 18 -24 year olds Limiting access / visibility – retail displays being removed. “Out of sight out of mind” NRT, bupropion and other approved cessation medications Eliminating provincial sales tax in Ontario on nicotine replacement products``

NRT and Reduction • • • 121 Cleaner, safer delivery system of nicotine Separates addictive behaviour from harm Prevents use of tobacco products to help withdrawal Increases familiarity with cessation products Combined with other treatment (behavioral, emotional triggers) New literature = start NRT two weeks before quit date http: //www. ash. org. uk/html/cessation/Smoking%20 reduction/NARS 0 51014. pdf

Evidence for Cardiovascular Harm: Nicotine in Animal Studies 122

Evidence for Cardiovascular Harm – Humans • • • 123 Blood pressure: older studies, higher resting BP, newer studies, no effect. Heart rate: mild increase but not significant Waist-hip: nil/variable BMI: variable Max workload capacity: no difference Insulin resistance higher risk both in long term NRT users. Variable in smokeless users. Asplund 2003; Progress in Cardiovascular Diseases

Conclusion • • 124 Nicotine may have increased cardiovascular effects that are associated with increased morbidity and mortality mainly in smokers. However, compared to smoked tobacco, other forms have less risk and at times are similar to that of non-smokers. In Sweden, many males switch to smokeless as a means to quit smoking. NRT appears to be safe. However long-term use only examined in the Lung Health Study 1996.

Evidence of Harm in Pregnancy • • • 125 Nicotine is a neuroteratogen However, CO and Thiocyanates also play a role Smoking is associated with cleft lip, low birth weight, SIDS Downstream psychiatric symptoms in children However, most pregnant women continue to smoke while pregnant even with the best available intervention. Fetocentric versus woman-centred approach

NRT in pregnancy • • 126 Try behavioural interventions first When cannot quit, try intermittent forms of NRT starting with lowest dose If using patch, remove at bedtime Continue behavioural support Benowitz et al, AJM: 2008

4 Cell Stage of Human Embryo A. Both parents smoke C. Mother smokes 127 Zenzes MT et al, Mol Human Reprod (1999) 5: 125 -131. B. Father smokes D. Nonsmoking parents

Cigarettes and Reproduction • • • 128 Women who smoke undergo menopause 1 to 4 years earlier than non-smokers. Zenzes et al have shown that smoking causes benzo(a)pyrene diol epoxide DNA (BPDE-DNA) adduct formation in human sperm Similar proportions of BPDE-DNA adducts in embryos where both parents smoke, compared to where only the father smoked, suggested that contribution of DNA adducts is mainly from sperm

Implications • 129 Understanding the role of nicotine in the harm caused by smoking is important if smokers are to be encouraged to use less harmful nicotine delivery devices and will help to identify where a cautious approach might be necessary as well as gaps for further research.

When does a person’s risk of developing lung cancer become high? ( > 10 times the risk of a non-smoker) a. Up to 10 cigarettes per day b. Between 10 -19 cigarettes per day c. 20 cigarettes per day d. Between 21 -31 cigarettes per day e. More than 31 cigarettes per day 130

Does Reduced Smoking Result in Less Harm? A Cautious Example Table 1: Risk of developing lung cancer as a function of the number of cigarettes /day # Cigarettes day (c. p. d) 0 (non smoker) 1. 0 1 -10 5. 5 11 -19 11. 2 20 14. 2 21 -31 20. 4 >31 131 Related Risk 22. 0 The more you smoke the more at risk you are of developing health issues. The opposite in not necessarily true as smokers can titrate the amount they get from each cigarette therefore getting more from less

What about………. One can contains 4 x the nicotine in a pack of cigarettes Tobacco or tobacco blends that are chewed or sucked on. A person who uses eight to 10 dips or chews a day receives the same amount of nicotine as a heavy smoker who smokes 30 to 40 cigarettes a day 132 http: //www. tobaccofacts. org/tob_truth/spit. html

Snuff, Chews and Plugs…… Snuff – Fermented, ground-up moist tobacco usually placed between the bottom lip and gum. This is also referred to as "dipping“ (Swedish form is Snus – lower risk). 133

Chew – shredded tobacco leaves placed between the cheek and gum. This is also referred to as "a wad". Plug – shredded tobacco leaves which are pressed into a hard block and placed between the cheek and gum 134

Ingredients in Smokeless Tobacco • • • 135 Nicotine: poisonous and highly addictive drug Carcinogens: many cancer-producing chemicals have been identified in smokeless (spit) tobacco. Sweeteners: tobacco has an unpleasant taste, some brands of smokeless tobacco are heavily sweetened with sugars, which promote tooth decay. Abrasives: scratch the soft tissues in the mouth, allowing the nicotine and other chemicals to get directly into the blood system. Salt: Flavouring salts found to contribute to abnormal blood pressure and kidney disease. Other Chemicals: Hundreds of other chemicals can be found in tobacco which contribute to many health problems.

Health Risks of Smokeless Tobacco (1) • • • Mouth Cancer – cancer of the cheeks, gums, lips and tongue. Smokeless (spit) tobacco users have a 50% higher chance of getting oral cancer than non-users. Throat Cancer – cancer of the voice box and cancer of the esophagus. Heart disease – heart attacks, strokes and high blood pressure. 136 http: //www. health. gov. sk. ca/rr_smokeless_tobacco. html

Health Risks of Smokeless Tobacco (2) • • 137 Dental diseases – stained teeth, tooth decay, receding gums, gum disease, bad breath and black hairy tongue. Stomach problems – ulcers, stomach upset, increased bowel activity and stomach cancer. Loss of taste and smell – causes loss of appetite which results in poor nutrition and poor health. Physical changes – fatigue, muscle weakness, dizziness and decreased physical performance, dermatologic changes http: //www. health. gov. sk. ca/rr_smokeless_tobacco. html

Cutaneous Manifestations of Smoking • • 138 a. Plethoric denotes a red florid complexion. Freiman et al. J Cutan Med Surg. 2004; 8(6): 415 -423. Prominent periorbital lines Gauntness Graying of the skin Plethorica complexion

Signs of Smoking Clinical Signs Harlequin nail Synonyms Quitter’s nail Description Demarcation line in the nail Smoker’s comedones Smoker’s face Large comedones with furrows and nodules a) Lines or wrinkles b) Gauntness c) Graying of the skin d) Plethoric complexion Smoker’s melanosis Smoker’s moustache Smoker’s nail Pigmentation of the gingiva Smoker’s palate 139 Moustache discoloration Nicotine sign Nicotine stomatitis, leukokeratosis nicotina palati Smoker’s tongue Leukokeratosis nicotina glossi Snuff dipper’s Smokeless tobacco lesion keratosis, Freiman et al. J Cutan Med Surg. 2004; 8(6): 415 -423. tobacco pouch keratosis Nail discoloration Coloration of the palatal mucosa Pink-coloured depressions White lesion in the oral cavity where smokeless tobacco is held

Smoking-Attributable Periodontitis • • • 140 Smoking is a major risk factor for periodontitis Current smokers are approximately 4 times as likely as persons who have never smoked to have periodontitis Periodontal disease is one of the main causes of tooth loss worldwide Tomar et al. J Periodontol. 2000; 71(5): 743 -751; http: //www. cdaadc. ca/en/oral_ health/complications/tobacco/ smokeless. asp. Accessed October 19, 2007.

Gum Recession 141

Leukoplakia 142

Brown Hairy Tongue 143 Davis. J Contemp Dent Pract. 2005; 6: 158 -166; Lewin et al. Cancer. 1998; 82: 1367 -1375. Nicotine Stomatitis

Oral Cancer 144

Smokeless Tobacco Prevention Websites • • 145 http: //mylastdip. com/ - Web-based intervention that is designed to help young chewing tobacco users quit. http: //www. chewfree. com/ - Website created to help people quit their use of chewing tobacco or snuff.

ST NRT Dosing Algorithm Spit Tobacco Algorithm ST / Week Patch / Gum / Lozenge Dosage 2 tins or less / week Patch: 14 mg. x 4 weeks 7 mg. x 4 weeks Gum / Lozenge*: 8 – 12 4 -mg pieces per day x 8 weeks (not to exceed 24/20 pieces per day) >2 but <5 tins / week Patch: 21 mg plus gum or lozenge* 21 mg x 4 weeks 14 mg x 2 weeks 7 mg x 2 weeks As needed gum / lozenge*: 4 – 8 pieces per day /4 mg OR: Gum / Lozenge*: 12 – 16 4 -mg pieces per day x 8 weeks (not to exceed 24/20 pieces per day) 5 or more tins/week Patch: 21 mg plus 4 -mg gum or lozenge*: 1 per waking hour OR: Gum/Lozenge*: 16 – 20 / 4 -mg gum or lozenge per day for 8 weeks (not to exceed 24/20 pieces per day) * for Lozenge enter First Tobacco Use to indicate within 30 minutes of waking © Dr. Herb Severson, Oregon Research Institute (ORI), 2010 Comments If patch adjust dosage to be 14 mg as starting dose. (14 mg x 4 weeks; 7 mg x 4 weeks) If prt is concurrently using any other form of tobacco w/ ST, increase starting dosage to 21 mg patch

Snus • • • a. The 147 Moist smokeless tobacco, snuff Although used worldwide, the highest consumption of snus is in Sweden Associated with an increased risk of pancreatic cancer (RR 2. 0; 95% CI, 1. 23. 3 a) probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people. Luo et al. Lancet. 2007. Epub ahead of print; http: //www. arnestadphotography. com/stock_photos/albums/concept/snuff_ tobacco_black. jpg. Accessed October 19, 2007.

Snus Different from other chew tobacco – it is sterilized, decreasing the number of nitrosamines (cancer-causing agents) • Reduced risk of lung cancer • No emphysema • 2 x risk of pancreatic cancer (down from 3 x risk with smoking) • 148

Snus • • • 149 International researchers followed 279, 897 male Swedish construction workers from 1978 to 1992. About 26 percent were snus users, 37 percent were smokers and the rest never used tobacco. For smokers, the incidence rate of pancreatic cancer was 13 cases per 100, 000 versus 8. 8 cases per 100, 000 for snus users. Among those who did not use tobacco, the rate was 3. 9 cases per 100, 000.

Hookah: Waterpipe Tobacco Smoking • • • 150 Shisha, a mixture of tobacco, molasses, and fruit flavors used in the hookah Water in the hookah does not diminish tobacco toxicity A 1 -hour session of hookah smoking exposes the user to 100 - 200 times the volume of smoke inhaled from a single cigarette Smoke produced contains high levels of carbon monoxide, heavy metals, and other carcinogens Delivers significant levels of nicotine World Health Organization. http: //www. who. int/tobacco/global_interaction/tobreg/Waterpipe%20 re commendation_Final. pdf; Sajid et al. J Pak Med Assoc. 1993; 43(9): 179 -182.

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Smokeless Tobacco as Harm Reduction? (1) • • • 153 As dependence-forming as cigarettes Users develop cravings and nicotine withdrawal when abstaining Does not produce second-handsmoke BUT people who dip or chew spread their germs when they spit. This increases the risk of passing an infection to others.

Smokeless Tobacco as Harm Reduction? (2) • • 154 90% of smokeless tobacco users are regular users before age 18 Almost all users are male High co-use of cigarettes (est. 10 -20%) 38% of users develop oral lesions within 3 years

Smokeless Tobacco Cessation • • • 155 Nicotine lozenge appears to be the most preferred cessation aid Presence of lesions is an opportunity to motivate behaviour change 2 week rule: If lesions do not heal within 2 weeks, recommend a biopsy

New Smokeless Cessation Aid. Mint Snuff • Non tobacco product, edible and made with real mint • Safe to swallow/eat • Available in 4 flavours • Mint Snuff Pouches are miniature teabags filled with Mint and Mint Oil Crystals. • 1 -800 -EAT-MINT 156 www. mintsnuff. com

Bottom Line on Harm Reduction Using fewer tobacco products may have little to no effect on reducing morbidity and mortality BUT Reducing consumption may increase likelihood of future cessation 157

What is your perspective on harm reduction and tobacco use? a. There is no such thing – all tobacco use is harmful b. I can see it that might be necessary with some populations c. I believe in using a harm reduction approach d. I’m not sure - I need more information 158

TEACH Exam

Evaluation and Wrap Up

TEACH Community of Practice & Listserv As a graduate of this course, you are eligible to join the TEACH Community of Practice Listserv! Our TEACH COP Listserv is configured so that you need to self-register, which quick and easy to do. To “subscribe” to the Listserv, please send an email to: teach-request@info 2. camh. net and write: “subscribe teach” in the subject line of your e-mail. You will then receive a message confirming your subscription to the List, as well as instructions on how to post or unsubscribe. 161

Course Evaluation: 3 Things to Remember 1. Please complete the Evaluation Form before you leave. 2. Log on to the TEACH Website to make sure you’ve completed Learning Assessments # 1& #2 (you must complete both in order to receive the CAMH Letter of Completion and U of T Certificate). 3. Online follow-up survey in three and six months – TEACH will send you a reminder ! 162

Are you interested in becoming a Tobacco Cessation Practice Leader? An Opportunity to…. • Develop your skills • Network • Attend TEACH courses • Achieve credit units Possible Roles…. . - Clinical Consultation - Conference Speaker - In –Service Trainer - Media Interviews - Resource Link Questions? Email: teach@camh. net 163

How would you rate this course? a. Excellent b. Very good c. Good d. Fair e. Poor 164

Please remember to leave your i-clicker on your table, Thanks. 165

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