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Understanding Tobacco’s Deadly Tolls on Individuals, Families, and Communities. Steven A. Schroeder, MD SAMHSA’s State Policy Academy on Tobacco Control in Behavioral Health June 19, 2014 Presentation courtesy of the Smoking Cessation Leadership Center and Rx for Change.

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Understanding tobacco s deadly tolls on individuals families and communities

Understanding Tobacco’s Deadly Tolls on Individuals, Families, and Communities

Steven A. Schroeder, MD

SAMHSA’s State Policy Academy on Tobacco Control in Behavioral Health

June 19, 2014

Presentation courtesy of the Smoking Cessation Leadership Center and Rx for Change

The health consequences of smoking 50 years of progress a report of the surgeon general
The Families, and CommunitiesHealth Consequences of Smoking:50 Years of ProgressA Report of the Surgeon General



50 years of tobacco control jama
50 Years of Tobacco Control Families, and CommunitiesJAMA

Facts about smoking and health
Facts About Smoking and Health Families, and Communities

Tobacco s deadly toll
Tobacco’s Deadly Toll Families, and Communities

  • 480,000 deaths in the U.S. each year

  • 4.8 million deaths world wide each year

  • 10 million deaths estimated by year 2030

  • 50,000 deaths in the U.S. due to second-hand smoke exposure

  • 16 million in U.S. with smoking related diseases

  • 45.3 million smokers in U.S. (78% daily smokers, averaging 13 cigarettes/day, 2012)

Understanding tobacco s deadly tolls on individuals families and communities

* Families, and Communities

Also suffer frommental illness and/or substance abuse

Behavioral Causes of Annual Deaths in the United States, 2000


Number of deaths (thousands)



Sexual Alcohol Motor Guns Drug Obesity/ Smoking

Behavior Vehicle Induced Inactivity

Source: Mokdad et al, JAMA 2004; 291:1238-1245

Mokdad et al; JAMA. 2005; 293:293


Health consequences of smoking

Cancers Families, and Communities

Acute myeloid leukemia

Bladder and kidney


Colon, liver, pancreas





Oral cavity and pharyngeal

Prostate (↓survival)

Pulmonary diseases

Acute (e.g., pneumonia)

Chronic (e.g., COPD)


Cardiovascular diseases

Abdominal aortic aneurysm

Coronary heart disease

Cerebro-vascular disease

Peripheral arterial disease

Type 2 diabetes mellitus

Reproductive effects

Reduced fertility in women

Poor pregnancy outcomes (ectopic pregnancy, congenital anomalies, low birth weight, preterm delivery)

Infant mortality; childhood obesity

Other effects: cataract; osteoporosis; Crohns; periodontitis,; poor surgical outcomes; Alzheimers; rheumatoid arthritis; less sleep

Health Consequences of Smoking

U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General, 2010.

Smoking and behavioral health the heavy burden
Smoking and Behavioral Health: Families, and CommunitiesThe Heavy Burden

  • 200,000 annual deaths from smoking occur among patients with CMI and/or substance abuse

  • This population consumes 40% of all cigarettes sold in the United States

    -- higher prevalence

    -- smoke more

    -- more likely to smoke down to the butt

  • People with CMI die earlier than others, and smoking is a large contributor to that early mortality

  • Greater risk for nicotine withdrawal

  • Social isolation from smoking compounds the social stigma

Industry targets bh population
Industry Targets BH population Families, and Communities

  • Pushed Doral to homeless shelters, and psychiatric facilities

  • R .J. Reynolds &"consumer subcultures,“(gay/Castro)" and "street people”

Sub Culture Urban Marketing

Financial impact
Financial Impact Families, and Communities

People with mental illnesses and/or addictions may spend up to 1/3 their income on cigarettes

A pack a day smoker spends on average…

$6.50 per day

$45.00 per week

$180 per month

$2,160 per year

$21,680 per 10 years

Steinberg, 2004

Compounds in tobacco smoke
Compounds in Tobacco Smoke Families, and Communities

An estimated 7,000 compounds in tobacco smoke, including 69 proven human carcinogens



  • Carbon monoxide

  • Hydrogen cyanide

  • Ammonia

  • Benzene

  • Formaldehyde

  • Nicotine

  • Nitrosamines

  • Lead

  • Cadmium

  • Polonium-210

Nicotine does NOT cause the ill health effects of tobacco use.

Causal associations with second hand smoke
Causal Associations with Families, and CommunitiesSecond-hand Smoke

There is no safe level of second-hand smoke.

  • Developmental

    • Low birthweight

    • Sudden infant death syndrome (SIDS)

    • Pre-term delivery

    • -- Childhood depression

  • Respiratory

    • Asthma induction and exacerbation

    • Eye and nasal irritation

    • Bronchitis, pneumonia, otitis media, bruxism in children

    • Decreased hearing in teens

  • Carcinogenic

    • Lung cancer

    • Nasal sinus cancer

    • Breast cancer (younger, premenopausal women)

  • Cardiovascular

    • Heart disease mortality

    • Acute and chronic coronary heart disease morbidity

    • Altered vascular properties

USDHHS. (2006).The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General.

Epidemiology of tobacco use
Epidemiology of Tobacco Use Families, and Communities

Trends in adult smoking by sex u s 1955 2012
TRENDS in ADULT SMOKING, Families, and Communitiesby SEX—U.S., 1955–2012

Trends in cigarette current smoking among persons aged 18 or older

18% of adults are current smokers







70% want to quit

Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2010 NHIS. Estimates since 1992 include some-day smoking.

Prevalence of adult smoking by education u s 2011
PREVALENCE of ADULT SMOKING, Families, and Communitiesby EDUCATION—U.S., 2011

25.1% No high school diploma

45.3% GED diploma

23.8% High school graduate

22.3% Some college

9.3% Undergraduate degree

5.0% Graduate degree

Centers for Disease Control and Prevention. (2012). MMWR 61(44);889-894.

Smoking prevalence and average number of cigarettes smoked per day per current smoker 1965 2010
Smoking Prevalence and Average Number of Cigarettes Families, and CommunitiesSmoked per Day per Current Smoker 1965-2010*

Percent/Number of Cigarettes Smoked Daily

* Schroeder, JAMA 2012; 308:1586

Smoking prevalence by mh diagnosis
Smoking Prevalence by MH Diagnosis Families, and Communities

2007 NHIS data

  • Schizophrenia 59.1%

  • Bipolar disorder 46.4%

  • ADD/ADHD 37.2%

    Current smoking:

  • 1 MH 31.9%

  • 2 MH 41.8%

  • 3+ MH 61.4%

    Grant et al., 2004, Lasser et al., 2000

  • Major depression 45-50%

  • Bipolar disorder 50-70%

  • Schizophrenia 70-90%

Smoking prevalence and substance abuse
Smoking Prevalence and Substance Abuse Families, and Communities

  • 53-91% of people in addiction treatment settings use tobacco (Guydish et al, Nicotine and Tobacco Research, June 2011, p 401)

  • Tobacco use causes more deaths than the alcohol or drug use bringing clients to treatment: death rates among tobacco users is nearly 1.5 times the rate of death from other addiction-related causes (SAMHSA N-SSATS Report September 2013)

  • In 2011, < half (42%) of U.S. substance abuse treatment facilities —offered tobacco cessation services (SAMHSA N-SSATS Report September 2013)

Smoking and the justice involved population
Smoking and the Families, and CommunitiesJustice Involved Population

  • 70 - 80% of men smoke;

  • 44 - 91% of women smoke

  • Prisoners have greater number of comorbidities, including MI and SA issues.

  • 97% of inmates in a smoke-free prison usually revert to smoking within six months of their release

Understanding tobacco s deadly tolls on individuals families and communities

30%-35% of Behavioral Health Health Providers Families, and CommunitiesSmoke

Compared to general health care providersPrimary Care Physicians 1.7 %Emergency Physicians 5.7 %Psychiatrists 3.2 % Registered Nurses 13.1%Dentists 5.8 %Dental Hygienists 5.4 %Pharmacists 4.5 %

NASMHPD Research Institute, Inc. (2006). Survey on Smoking Policies and Practices for Psychiatric Facilities.

Strouse R, Hall J and Kovac M. Survey of Health Professionals' Knowledge, Attitudes, Beliefs, and Behaviors Regarding Smoking Cessation Assistance and Counseling. Princeton, N.J.: Mathematica Policy Research, Inc., 2004, 1-16.

Benefits of tobacco control in the unites states 1964 2012
Benefits of Tobacco Control in the Unites States, 1964-2012* Families, and Communities

  • 17.7 smoking-related deaths occurred

  • 8 million such deaths prevented

  • Preventing smoking-related deaths accounted for 30% of life expectancy gains during that period!

  • People with mental illness did not benefit as much from these declines in smoking rates

    * Holford et al ; Cook et al,JAMA, 2014

Nri survey
NRI Survey Families, and Communities

*Response rates: 2005 – 55%, 2006 – 82%, 2008 – 75%, 2011 – 80%

Source: Schacht L, Ortiz G, Lane M. Smoking Policies and Practices in State Psychiatric Hospitals 2011. National Association of State Mental Health Program Directors Research Institute, Inc. Feb 29, 2012.

Clinical issues
Clinical Issues Families, and Communities

Myths about smoking and behavioral health
Myths About Smoking and Behavioral Health Families, and Communities

  • Tobacco is necessary self-medication (industry has supported this myth)

  • They are not interested in quitting (same % wish to quit as general population)

  • They can’t quit (quit rates same or slightly lower than general population)

  • Quitting worsens recovery from the mental illness (not so; and quitting increases sobriety for alcoholics)

  • It is a low priority problem (smoking is the biggest killer for those with mental illness or substance abuse issues)

    Prochaska, NEJM, July 21, 2011

Understanding tobacco s deadly tolls on individuals families and communities

Dopamine Reward Pathway Families, and Communities

Prefrontal cortex

Dopamine release

Stimulation of nicotine receptors

Nucleus accumbens

Ventral tegmental area

Nicotine enters brain

Nicotine addiction
Nicotine Addiction Families, and Communities

  • Tobacco users maintain a minimum serum nicotine concentration in order to

    • Prevent withdrawal symptoms

    • Maintain pleasure/arousal

    • Modulate mood

  • Users self-titrate nicotine intake by

    • Smoking more frequently

    • Smoking more intensely

    • Obstructing vents on low-nicotine brand cigarettes

  • Nicotine exposure heightens pleasure from cocaine in rat model (Science Trans Med, 11/2/2011)

Tools for smoking cessation
Tools for Smoking Cessation Families, and Communities

  • 5A’s (Ask, Advise, Assess, Assist, Arrange)

  • AAR (Ask, Advise, Refer)

  • Quitlines

  • NRT and other medications

  • Counseling and behavioral change strategies

  • Peer-to-peer intervention

Ask advise refer 5 a s
Ask. Advise. Refer. = 5 A’s Families, and Communities


Ask. Every patient/client about tobacco use.




Advise. Every tobacco user to quit.


Refer. Determine willingness to quit. Provide information on quitlines.

Refer to Quitlines

Portal to other services

ADHA Smoking Cessation Initiative (SCI)

Quitlines and behavioral health
Quitlines and Behavioral Health Families, and Communities

Do quitlines work for people with MI and/or SUD?

Are they able to meet the demand?

Behavioral health advisory forum screening and training
Behavioral Health Advisory Families, and CommunitiesForum Screening and Training

  • NAQC standard optional question(s) for the Minimal Data Set*

    • Do you have any mental health issues or emotional challenges, such as an anxiety disorder, depression disorder, bipolar disorder, alcohol/drug abuse, or schizophrenia?

    • Do you believe that these mental health issues or emotional challenges will interfere with your ability to quit?

  • Developed a standardized training curriculum for quitline tobacco treatment specialists

    * Do Quitlines Have a Role in Serving the Tobacco Cessation Needs of Persons with Mental Illnesses and Substance Use Disorders? The Behavioral Health Advisory Forum (BHAF), Background Report, September 2010.

Caveats about cessation literature
Caveats About Cessation Literature Families, and Communities

  • Smoking should be thought of as a chronic condition, yet drug treatment often short (12 weeks) in contrast to methadone maintenance

  • Great spectrum of severity and addiction; treatment should be tailored accordingly

  • Volunteers for studies likely to be more motivated to quit

  • Placebo and drug groups tend to have more intensive counseling than found in real practice world; and counseling is not a monolithic black box

  • Most drug trials excluded patients with mental illness

Long term 6 month quit rates for available cessation medications








Percent quit








Data adapted from Cahill et al. (2012). Cochrane Database Syst Rev;Stead et al. (2012).

Cochrane Database Syst Rev; Hughes et al. (2007). Cochrane Database Syst Rev

Treatment Families, and Communities

  • Persons with mental illnesses and substance abuse disorders benefit by the same interventions as the general population

  • A combination of counseling and pharmacotherapy should be used whenever possible

  • Duration of treatment might be longer

  • View failed quit attempt as a practice, not failure

Reduction vs abrupt cessation in smokers who want to quit
Reduction vs. Abrupt Cessation in Smokers Who Want to Quit Families, and Communities

  • There are two schedules to stop smoking BH population: immediate cessation versus gradual reduction. As of now, there is no clear evidence supporting one over the other.

  • Give smokers a choice as to whether they would prefer to abruptly quit or gradually reduce

  • Risks from lower intensity smoking are not much less than higher intensity.

Source: Lindson, N., Aveyard, P., & Hughes J.R. (2010).  Reduction versus abrupt cessation in smokers who want to quit. Cochrane Database of Systematic Reviews, Issue 3.

Power of peers
Power of Peers Families, and Communities

  • Peer-led support groups, community referrals, etc.

  • Train peers to integrate tobacco cessation & wellness services into existing roles and responsibilities.

  • “Embedded” model uses programs that have peer specialists on staff or as volunteers

Conclusion and next steps
Conclusion and Next Steps Families, and Communities

Surgeon general s report commission 2014
Surgeon General’s Report Commission (2014) Families, and Communities

  • Reduce smoking rates, currently at about 18 percent, to less than 10 percent within 10 years (“10 in 10”);

  • Protect all American from second hand smoke with five year; and

  • Ultimately eliminate the death and disease caused by tobacco use

The electronic cigarette
The Electronic Cigarette* Families, and Communities

  • Aerosolizes nicotine in propylene glycol solvent

  • Cartridges contain about 20 mg nicotine

  • Safety unproven, but >cigarette smoke

  • Bridge use or starter product?

  • Probably deliver < nicotine than promised

  • Not FDA approved; predatory marketing

  • My advice: avoid unless patient insists

    *Cobb & Abrams. NEJM July 21, 2011; Fiore, Schroeder, Baker, NEJM Jan 23, 2014

Smoking profile 2014
Smoking Profile, 2014 Families, and Communities

  • Policymakers live in a non-smoking “gated community”

  • Smoking now marginalized to the poor and the disadvantaged, plus some “young immortals”

  • Thus tobacco control=social justice issue

  • Tobacco industry fights domestic rear guard action while expanding overseas