1. Steven A. Schroeder, MD Professor of Medicine University of California San Francisco San Francisco, California Get Your Patients with HIV/AIDS to Stop Smoking Before it Kills Them FORMATTED: 11/03/2015 New Orleans, Louisiana: December 15-17, 2015

2. Slide 2 of 56 Tobacco’s Deadly Toll 540,000 deaths in the U.S. each year* 540,000 deaths in the U.S. each year* 4.8 million deaths world wide each year 4.8 million deaths world wide each year --Current trends show >8 million deaths annually by 2030 42,000 deaths in the U.S. due to second-hand smoke exposure 42,000 deaths in the U.S. due to second-hand smoke exposure 14 million in U.S. with smoking related diseases 14 million in U.S. with smoking related diseases (60% with COPD) (60% with COPD) 42.1 million smokers in U.S. (76.9% daily smokers, averaging 14.2 cigarettes/day, 2013) 42.1 million smokers in U.S. (76.9% daily smokers, averaging 14.2 cigarettes/day, 2013) * Carter et al, NEJM, Feb 12, 2015

3. Slide 3 of 56 TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2013 20.5% 15.3% Trends in cigarette current smoking among persons aged 18 or older Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2013 NHIS. Estimates since 1992 include some-day smoking. 68.8% want to quit 17.8% of adults are current smokers Male Female Percent

4. Slide 4 of 56 Smoking Prevalence and Average Number of Cigarettes Smoked per Day per Current Smoker 1965-2010 Source: Schroeder, JAMA 2012; 308:1586; *CDC/NCHS, National Health Interview Survey, 1997-March 2015, Sample Adult Core Percent/Number of Cigarettes Smoked Daily *January-March 2015: 15.3% prevalence!

5. Slide 5 of 56 Health Consequences of Smoking U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General, 2010. Cancers Cancers –Acute myeloid leukemia –Bladder and kidney –Cervical –Colon, liver, pancreas –Esophageal –Gastric –Laryngeal –Lung –Oral cavity and pharyngeal –Prostate ( ↓ survival) Pulmonary diseases Pulmonary diseases –Acute (e.g., pneumonia) –Chronic (e.g., COPD) –Tuberculosis Cardiovascular diseases Cardiovascular diseases –Abdominal aortic aneurysm –Coronary heart disease –Cerebro-vascular disease –Peripheral arterial disease –Type 2 diabetes mellitus Reproductive effects 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; Crohn’s; periodontitis; poor surgical outcomes; Alzheimer’s; rheumatoid arthritis; less sleep Other effects: cataract; osteoporosis; Crohn’s; periodontitis; poor surgical outcomes; Alzheimer’s; rheumatoid arthritis; less sleep

6. Slide 6 of 56 Causal Associations with Second-hand Smoke Developmental Developmental –Low birthweight –Sudden infant death syndrome (SIDS) –Pre-term delivery -- Childhood depression Respiratory Respiratory –Asthma induction and exacerbation –Eye and nasal irritation –Bronchitis, pneumonia, otitis media, bruxism in children –Decreased hearing in teens Carcinogenic Carcinogenic –Lung cancer –Nasal sinus cancer –Breast cancer? (younger, premenopausal women) Cardiovascular 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. There is no safe level of second-hand smoke.

7. Slide 7 of 56 Smoking and Behavioral Health: The Heavy Burden 240,000 annual deaths from smoking occur among patients with Chronic Mental Illness (CMI) and/or substance abuse 240,000 annual deaths from smoking occur among patients with Chronic Mental Illness (CMI) and/or substance abuse This population consumes 40% of all cigarettes sold in the United States 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 People with CMI die earlier than others, and smoking is a large contributor to that early mortality Greater risk for nicotine withdrawal Greater risk for nicotine withdrawal Social isolation from smoking compounds the social stigma Social isolation from smoking compounds the social stigma

8. Slide 8 of 56 Smoking Imperils the HIV/AIDS Population LGBT persons and those with substance use disorders have higher smoking rates LGBT persons and those with substance use disorders have higher smoking rates HIV/AIDS patients have higher smoking rates HIV/AIDS patients have higher smoking rates HIV patients who smoke have greater odds of heart disease, cancer, CVA, and HIV-related infections than HIV patients who do not smoke HIV patients who smoke have greater odds of heart disease, cancer, CVA, and HIV-related infections than HIV patients who do not smoke

9. Slide 9 of 56 Nicotine enters brain Stimulation of nicotine receptors Dopamine release Dopamine Reward Pathway Prefrontal cortex Nucleus accumbens Ventral tegmental area

10. Slide 10 of 56 Nicotine Addiction 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

11. Slide 11 of 56 Tools for Smoking Cessation 5As (Ask, Advise, Assess, Assist, Arrange) AAR (Ask, Advise, Refer) Quitlines NRT and other medications Counseling and behavioral change strategies Peer-to-peer intervention

12. Slide 12 of 56Treatment Persons with HIV, mental illnesses, and substance use disorders benefit from same interventions as general population 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

13. Slide 13 of 56 Cognitive Strategies for Cessation Review commitment to quit, focus on downsides of tobacco use Reframe the way a patient thinks about smoking Distractive thinking Positive self-talks, “pep talks” Relaxation through imagery Mental rehearsal, visualization

14. Slide 14 of 56 Behavioral Strategies for Cessation (Avoiding Stimuli that Trigger Smoking) Stress – –Anticipate future challenges – –Develop substitutes for tobacco Alcohol – –Limit or abstain during early stages of quitting Other tobacco users – –Stay away – –Ask for cooperation from family and friends

15. Slide 15 of 56 Behavioral Strategies for Cessation (Part 2) Oral gratification needs – –Use substitutes: water, sugar-free chewing gum or hard candies Automatic smoking routines – –Anticipate routines and develop alternative plans, e.g., with morning coffee Weight gain after cessation – –Anticipate; use gum or bupropion; exercise Cravings – –Distractive thinking; change activities

16. Slide 16 of 56PHARMACOTHERAPY Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008. Medications significantly improve success rates. * Includes pregnant women, smokeless tobacco users, light smokers, and adolescents. “Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations* for which there is insufficient evidence of effectiveness.”

17. Slide 17 of 56 Pharmacologic Methods: First-line Therapies* Three general classes of FDA-approved medications for smoking cessation:   Nicotine replacement therapy (NRT) -- nicotine gum, patch, lozenge, nasal spray, inhaler   Partial nicotine receptor agonist -- varenicline --? cytisine in the future   Psychotropics -- sustained-release bupropion * Counseling plus meds better than either alone Currently, no medications have an FDA indication for use in spit tobacco cessation.

18. Slide 18 of 56 Caveats About Cessation Literature 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 exclude patients with mental illness

19. Slide 19 of 56 LONG-TERM (  6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS 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 Percent quit 16.3 15.9 10.0 9.8 18.9 8.4 23.9 11.8 17.1 9.1 18.9 10.6 12.0 28.0

20. Slide 20 of 56 Quitlines and Behavioral Health Do quitlines work for people with MI and/or SUD? Yes Do quitlines work for people with MI and/or SUD? Yes Are they able to meet the demand? They are underused Are they able to meet the demand? They are underused

21. Slide 21 of 56 Tips for Your Office Referral forms to the quitline (1-800-QUITNOW) Referral forms to the quitline (1-800-QUITNOW) Carbon monoxide breathalyzer (cost about $500 plus disposal mouthpieces) Carbon monoxide breathalyzer (cost about $500 plus disposal mouthpieces) One key question to ask: “When do you have your first cigarette of the day?” One key question to ask: “When do you have your first cigarette of the day?” Approach smoking as a chronic illness, just like HIV/AIDS in 2015 Approach smoking as a chronic illness, just like HIV/AIDS in 2015

22. Slide 22 of 56 Contact SCLC for Technical Assistance Visit us online http://smokingcessationleadership.ucsf.edu http://smokingcessationleadership.ucsf.edu http://smokingcessationleadership.ucsf.edu –CME/CE webinars –Fact sheets, toolkits, publications –Training resources and presentations –E-newsletter and listserv –Online ordering for 1-800-QUIT NOW cards Call us toll-free 1-877-509-3786 1-877-509-3786

23. Slide 23 of 56 The Electronic Cigarette* Aerosolizes nicotine in propylene glycol solvent; e-cig products in evolution Aerosolizes nicotine in propylene glycol solvent; e-cig products in evolution Cartridges contain about 20 mg nicotine Cartridges contain about 20 mg nicotine Safety unproven, but >cigarette smoke Safety unproven, but >cigarette smoke Probably deliver < nicotine than promised Probably deliver < nicotine than promised Unclear if help smokers quit Unclear if help smokers quit Not approved by FDA Not approved by FDA My advice: avoid unless patient insists My advice: avoid unless patient insists * Cobb & Abrams. NEJM July 21, 2011; Fiore, Schroeder, Baker, NEJM Jan 23, 2014

24. Slide 24 of 56 Cigarette and E-Cigarette Use among High School Students, 2000-2014 Source: Youth Risk Behavior Survey