A 2014 REPORT, 50 YEARS OF PROGRESS: A Report of the Surgeon General,(1) which chronicles the devastating consequences of 50 years of tobacco use in the United States, finds that while the prevalence of current cigarette smoking among adults has declined from 42 percent in 1965 to 18 percent in 2012, more than 42 million Americans still smoke. Tobacco has killed more than 20 million people prematurely since the first surgeon general’s report in 1964. And there is more bad news: The report shows that the decline in the prevalence of smoking has slowed in recent years, and smoking-attributable mortality is expected to remain at high and unacceptable levels for decades unless urgent action is taken.
Smoking-Related Disease Prevention
According to the U.S. surgeon general, evidence-based tobacco control interventions that are effective continue to be underused. “What we know works to prevent smoking initiation and promote quitting includes hard-hitting media campaigns, tobacco excise taxes at sufficiently high rates to deter youth smoking and promote quitting, easy-to-access cessation treatment and promotion of cessation treatment in clinical settings, smoke-free policies and comprehensive statewide tobacco control programs funded at CDC-recommended levels.”
Smoking remains the single largest cause of preventable disease and death in the United States, according to the surgeon general report. So what do you do when admitted smokers walk into your office? Talk to them.
Talking to Patients
Karen Konarski-Hart, DC, DABCO, FACO, EMT, president of ACA’s Council of Delegates, former president of the Arkansas State Board of Health and owner of a private practice, points out that SOAP notes expect the doctor of chiropractic to write down social history. (See “Keep Your Records Clean With SOAP,” November 2014 ACA News at www. acatoday.org/content_css.cfm?CID=5341.) Whether or not a patient smokes is part of the intake form.
“There is always a question asking if you smoke and how much you smoke, what you smoke,” she says. The obvious answer is that most people smell as if they smoke, especially if you’re a nonsmoker. “The second step is when you go over the intake form to ask, how much do you smoke?”
“There is a lot of evidence on why smoking cessation is beneficial, and it’s important to be well-read on this subject so that your patient discussions are natural and you can feed the information into your treatment discussion,” Dr. Konarski-Hart says.
A 2006 study(2) concluded that chiropractic interns can and should be encouraged to advise smokers about cessation. It found that a systematic method of intake information on smoking status is needed and a standardized education protocol for chiropractic colleges is needed. Chiropractic colleges should assess the adequacy of their advising roles and implement changes to increase cessation messages to their patients as soon as possible.
The study points out that for those with chronic spine conditions, smoking is often the No. 1 co-morbidity reported, yet few patients have ever been advised to quit or told how. The study’s authors found a clear need for development of a standardized delivery method on smoking cessation education for interns to be made part of the chiropractic college curriculum. Such a campaign was implemented at Parker University as an integral part of a class on wellness required in students’ fifth trimester before interns see patients.
The Issue of Desire
Assuming many patients’ first contact with a chiropractic physician is for a musculoskeletal neurological-type issue, Dr. Konarski-Hart says the most important question is whether or not a patient is determined to stop smoking. “The patient has to want to stop, and if the patient is not serious at all, it won’t work,” she says. “You can have all the best cessation programs, but if the patient isn’t on board, you have lost the most important part of the program.”
If the patient is committed to giving up smoking, does he or she have a program or method in mind? “If the patient already has a plan in mind and feels good about it, I try to support whatever program my patients want to use,” Dr. Konarski-Hart says. “I may point out some failings or a way the plan can be enhanced.”
Some are capable of simply quitting. “A person may have the willpower, want to go cold turkey and throw everything in the trash,” says Dr. Konarski-Hart. “Some want to wean off and may need moral support, while others go with medication- enhanced help, whether it is nicotine gum or nicotine patches.” DCs need to do whatever is needed to help them in the process, such as giving referrals or information.
Dr. Konarski-Hart asks her patients if there are triggers. What makes them smoke? She points out the importance of finding out if they constantly smoke or only after meals, when with friends, while watching TV, at bars/restaurants or at night. She tells them to break their patterns. “I tell them to do whatever they can to eliminate those triggers. For instance, if they smoke after meals, then when done eating, get up and go for a walk,” she says. It’s important to find substitutes in place of smoking. There are good ones and bad ones. “Positive options are better, because if they are going to eat more when they stop smoking, that is not the best way to go.”
Changing the environment helps. Clean up the house. “The best thing a person can do that is serious about quitting is getting the house deep cleaned and purged of all the smoking smell,” Dr. Konarski-Hart says.
A popular program you can recommend is the American Lung Association’s “Freedom From Smoking,” which is a group clinic consisting of eight sessions. It is delivered by an American Lung Association trained facilitator in a small-group setting (usually 8 to 10 people), so participants are given personalized attention. At the same time, individuals benefit from the peer support. The current edition of the curriculum includes the latest research about nicotine replacement therapy (e.g., gum, inhalers, patches, lozenges and nasal spray) and other smoking cessation medications, such as Zyban and Chantix.
Participants can use the group clinic by itself or in conjunction with the Freedom From Smoking self-help manual, the American Lung Association’s Lung HelpLine (1-800-LUNG-USA) and Freedom From Smoking Online program at www.ffsonline.org.
Dr. Konarski-Hart recommends a program called Stamp Out Smoking, (SOS) run by the Arkansas Department of Public Health as its primary smoking cessation program. (Go to www.stampoutsmoking.com.) She explains how the program works: The doctor has the patient sign a form to state his or her commitment to cessation and gives the doctor permission to have SOS staff contact the patient. The doctor sends the patient contact info to SOS, which then has a smoking cessation expert contact the patient and help find the best program. SOS continues to mentor the patient and provide any resources the patient needs. Basically, the doctor is a referring partner but gives the psychological and continuing support function to an expert. SOS also provides supplies to the doctor (e.g., tips on talking to patients, patient info, forms, etc).
Smoking and Vitamin Depletion
Many vitamins and minerals are depleted in smokers, and supplements are useful in rejuvenating a smoker’s body. Vitamin C(3) is depleted in smokers and in children exposed to tobacco smoke,(4) with supplementation recommended for both groups.
Chronic smoking is associated with lower systemic status of several B vitamins, reduced oral folate and changes in folate form distribution in the mouth.(5)
Vitamin E disappearance is accelerated in cigarette smokers due to increased oxidative stress and is inversely correlated with plasma vitamin C concentrations. The research finds that the vitamin E depletion can be normalized with vitamin C.(6)
The good news is that most of the damage can be reversed by smoking cessation. A study from the British Journal of Nutrition finds that given the importance of cigarette smoking as a risk factor for cardiovascular diseases and the pathophysiological role played by oxidative stress in these illnesses, quitting smoking represents an irreplaceable preventive strategy against tobacco-induced oxidative stress and vascular damage.(7) But that is tempered by research showing that although most smokinginduced changes are reversible after quitting, some inflammatory mediators like C-reactive protein (CRP) are still significantly raised in ex-smokers up to 10 to 20 years after quitting, suggesting ongoing low-grade inflammatory response persisting in former smokers.(8)
As recovering smokers stop the habit, they will notice that food and drink taste different and better. “They find that food has more subtle or more interesting flavors, and it gives them something to look forward to,” says Dr. Konarski-Hart. “I tell patients to take low-dose chewable vitamin C also to help with the oral fixation.”
Exercise is needed for cardiovascular health; less stressful exercises that increase breathing and respiration can be beneficial, like classes in Qigong, an ancient Chinese health care system that integrates physical postures, breathing techniques and focused intention. “Anything that is relaxing but focuses on breathing and helps with grounding is beneficial, in case the patient is more agitated or nervous when going through nicotine withdrawal,” says Dr. Konarski-Hart.
Numerous studies have pointed out that smoking increases the risk of back pain.(9,10) DCs can help with a number of methods, such as use of acupuncture to diminish the nervousness and agitation problems as smokers are quitting. “Massage removes toxins, and manipulation improves body function, so they can move better and wake their bodies back up,” says Dr. Konarski-Hart.
Will Incentives Work in Low-Income Populations?
IT’S TOO SOON TO TELL. Section 4108 of the PPACA mandated creation of the Medicaid Incentives for Prevention of Chronic Diseases (MIPCD) program for states to develop evidence-based prevention programs that provide incentives to Medicaid beneficiaries upon participation in the program. Smoking cessation was targeted along with diabetes, obesity, hyperlipidemia and hypertension. In September 2011, 10 states (e.g., California, Connecticut, Hawaii, Minnesota, Montana, Nevada, New Hampshire, New York, Texas and Wisconsin) were awarded demonstration grants to implement chronic disease prevention approaches for their Medicaid enrollees to test the use of incentives to encourage behavioral change.
In November 2013, CMS released an interim evaluation of program eff ectiveness, finding it too early to recommend whether funding for expanding or extending the programs should be granted beyond Jan. 1, 2016. Incentives range from $20 to $1,150 annually and are used to reward participants for achieving specified health outcomes. Six states are targeting diabetes and smoking. Some have found reaching their enrollment targets difficult and, therefore, lack a large enough participant population to conduct their evaluation analyses. California is conducting a post-intervention seven-month follow-up assessment and has found it difficult to engage control group participants in assessment. Some states have revised their evaluation plans and analyses to address enrollment challenges and other implementation delays. The 108- page report can be accessed at http://innovation.cms.gov/Files/reports/MIPCD_RTC.pdf.
Tobacco Removed From Stores
ON SEPT. 3, 2014, CVS HEALTH announced the company had stopped selling tobacco products in its 7,700 stores. According to the release, “Tobacco is the only product that, when used as directed, kills. Every year, more than 480,000 Americans die and millions more get sick due to tobacco use. Tobacco use results in more than $289 billion in health care and related costs.” Target and Wegmans also removed tobacco from their shelves. It is part of a larger effort on the part of these stores to have no sales of tobacco in stores with pharmacies and clinics.
DID YOU KNOW? According to the U.S. surgeon general, the estimated economic costs attributable to smoking and exposure to tobacco smoke continue to increase and now approach $300 billion annually, with direct medical costs of at least $130 billion and productivity losses of more than $150 billion a year. The facts are devastating:
• In the United States, smoking causes 87 percent of lung cancer deaths, 32 percent of coronary heart disease deaths and 79 percent of all cases of chronic obstructive pulmonary disease (COPD).
• One out of three cancer deaths is caused by smoking.
• Smoking causes colorectal and liver cancer and increases the failure rate of treatment for all cancers.
• Smoking causes diabetes mellitus, rheumatoid arthritis and immune system weakness, increased risk for tuberculosis disease and death, ectopic (tubal) pregnancy and impaired fertility, cleft lip and cleft palates in babies of women who smoke during early pregnancy, erectile dysfunction and age-related macular degeneration.
• Secondhand smoke exposure is now known to cause strokes in nonsmokers.
• Cigarette smoking diminishes overall health status, impairs immune function and reduces quality of life.
Source: 50 Years of Progress: A Report of the Surgeon General (2014).
Tobacco Is World’s Most Prevalent Addiction
POINTING OUT THAT ADDICTIVE BEHAVIORS are among the greatest scourges on humankind, Global Statistics on Addictive Behaviors: 2014 Status Report, published in Addiction on May 11, 2015, finds an estimated 22.5 percent of adults in the world (1 billion people) smoke tobacco products (32 percent of men and 7 percent of women). It is estimated that 11 percent of deaths in males and 6 percent of deaths in females each year are due to tobacco. The report is available at http://onlinelibrary.wiley.com/doi/10.1111/add.12899/full.
What about Electronic Cigarettes?
ELECTRONIC NICOTINE DELIVERY SYSTEMS (ENDS), which include e-cigarettes, are devices capable of delivering nicotine in an aerosolized form. The American Association for Cancer Research (AACR), in conjunction with Rep. Jackie Speier (D-Calif.) and Sen. Richard Blumenthal (D-Conn.), held a briefing titled, “Electronic Cigarettes: What You Don’t Know Can Hurt You,” on May 14, 2015, in the U.S. Capitol.
The increase in the use of electronic cigarettes and other electronic nicotine delivery systems (ENDS) has raised complex regulatory issues and public health concerns. The briefing aimed to educate attendees on the types of ENDS that are available, what is known about them and what we still need to learn to best protect public health. The speakers discussed a joint policy statement released in January 2015 by the AACR and the American Society of Clinical Oncology titled, Electronic Nicotine Delivery Systems: A Policy Statement From the American Association for Cancer Research and the American Society of Clinical Oncology. That reports recommends additional research on ENDS, including assessing their health impact, understanding use patterns and what role ENDS have in tobacco smoking cessation. Access the report at http://bit.ly/1ETcCKo.
50 Years of Progress: A Report of the Surgeon General, U.S. Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General, available online at www.surgeongeneral.gov/library/reports/50-years-of-progress/index.html.
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Lykkesfeldt, J et al., Ascorbate is depleted by smoking and repleted by moderate supplementation: a study in male smokers and nonsmokers with matched dietary antioxidant intakes. Am J Clin Nutr Feb 2000, vol. 71 no. 2 530-536. Available online at http://ajcn.nutrition.org/content/71/2/530.short.
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- Petre, B. et al., Smoking increases risk of pain chronification through shared corticostriatal circuitry. Human Brain Mapping, Volume 36, Issue 2, Pages 415–826. Available online at http://onlinelibrary. wiley.com/doi/10.1002/hbm.22656/abstract.