2. With special thanks to Dr. Ron LaporteWith special thanks to Dr. Ron Laporte
at University of Pittsburgh for emailingat University of Pittsburgh for emailing
and providing me with valuableand providing me with valuable
material and data to be used in thismaterial and data to be used in this
presentation……….presentation……….Nayyar R. KazmiNayyar R. Kazmi

3. There are almost 10-15 millionThere are almost 10-15 million
established smokers in Pakistanestablished smokers in Pakistan
Common in labourer class,Common in labourer class,
transport drivers, other lower socio-transport drivers, other lower socio-
economic groups as well as uppereconomic groups as well as upper
stratum of the societystratum of the society

4. Drug AddictsDrug Addicts Non Drug AddictsNon Drug Addicts
EstablishedEstablished
SmokersSmokers
257257 6262
Non-SmokersNon-Smokers 3939 134134
Kazmi NR, et al. Regular smoking as a risk factor in
drug addicts- A case control study in Peshawar- Int
Journal of Epidemiology: 2000. Vol.XXI, No.IV: 1554
Odds Ratio 14.24

5. Have you ever smoked a whole cigarette?
Ever tried – even a few puffs?
No – Never SmokerNever Smoker Yes
YesNo – TrierTrier Smoked > 1 whole cigarette?
No – TrierTrier Yes
On how many of last 30 days did you smoke?
None – < Monthly smoker< Monthly smoker < 20 days > 20 days – Established smokerEstablished smoker
On how many of last 7 days did you smoke?
None – Experimental SmokerExperimental Smoker At least one – Regular SmokerRegular Smoker
11
22
22
33
44 55
Stage Model of Smoking AcquisitionStage Model of Smoking Acquisition
66

6. Smoking by Age andSmoking by Age and
Stage of Onset*Stage of Onset*
AGE
*Source: The MACC Study

7. Tobacco Dependence as aTobacco Dependence as a
Chronic DiseaseChronic Disease
 Tobacco dependence demonstratesTobacco dependence demonstrates
features of a chronic disease:features of a chronic disease:
 Long-term disorderLong-term disorder
 Periods of relapse and remissionPeriods of relapse and remission
 Requires ongoing rather than acute careRequires ongoing rather than acute care

8. Smoking in PerspectiveSmoking in Perspective
Kills more than 440,000 Americans each yearKills more than 440,000 Americans each year
23% of adult Americans smoke23% of adult Americans smoke
3,000 children and adolescents become regular3,000 children and adolescents become regular
tobacco users every daytobacco users every day
Causes cancer, heart disease, stroke,Causes cancer, heart disease, stroke,
pulmonary disease, and adverse pregnancypulmonary disease, and adverse pregnancy
outcomes- shortens life expectancy 14 yearsoutcomes- shortens life expectancy 14 years
Adds $157 billion in costs per yearAdds $157 billion in costs per year
One-third of all tobacco users in U.S. will dieOne-third of all tobacco users in U.S. will die
prematurelyprematurely

9. Environmental Tobacco SmokeEnvironmental Tobacco Smoke
Kills one person prematurely, for every 8 people killed byKills one person prematurely, for every 8 people killed by
primary smokingprimary smoking
50,000 premature deaths each year50,000 premature deaths each year
1 million ER visits for asthma each year1 million ER visits for asthma each year
Causes all diseases primary smokeCauses all diseases primary smoke
60 carcinogens-formaldehyde, benzo[a]pyrene60 carcinogens-formaldehyde, benzo[a]pyrene
6 developmental toxicants, nicotine, CO6 developmental toxicants, nicotine, CO
The tobacco industry spends billions arguing the pointThe tobacco industry spends billions arguing the point

10. Perceived Health Risks
Among Cigarette Smokers
Heart attack Cancer
All smokers 29% 40%
Heavy smokers 39% 49%
Ayanian & Cleary JAMA 1999;281:1091-1021

11. Predictive Factors of YouthPredictive Factors of Youth
Smoking OnsetSmoking Onset
EnvironmentalEnvironmental
Access to cigarettesAccess to cigarettes
Exposure to marketingExposure to marketing
Peer use and supportPeer use and support
Sibling use and supportSibling use and support
Parental supportParental support
Normative expectationsNormative expectations
BehavioralBehavioral
Academic achievementAcademic achievement
Behavioral skillsBehavioral skills
Prior use of tobaccoPrior use of tobacco
Other problem behaviorsOther problem behaviors
Socio-DemographicSocio-Demographic
Low SESLow SES
Developmental stageDevelopmental stage
Intra-PersonalIntra-Personal
Functional meaningsFunctional meanings
of smokingof smoking
Low self-imageLow self-image
Self-efficacy to refuseSelf-efficacy to refuse
offersoffers
Personality factorsPersonality factors

12. Exposure to advertising, adult/sibling role modelsExposure to advertising, adult/sibling role models
who smoke cigarettes, and low academicwho smoke cigarettes, and low academic
achievementachievement
Peer influences to smoke, the perception thatPeer influences to smoke, the perception that
smoking is normative and functional, and socialsmoking is normative and functional, and social
access to cigarettes.access to cigarettes.
Social situations and peers that support smoking,Social situations and peers that support smoking,
low self-efficacy and skills to refuse offers tolow self-efficacy and skills to refuse offers to
smoke, and social/commercial access to cigarettes.smoke, and social/commercial access to cigarettes.
Peers who smoke, the perception that smoking hasPeers who smoke, the perception that smoking has
personal utility, social and commercial access topersonal utility, social and commercial access to
cigarettes, and few restrictions on smoking in thecigarettes, and few restrictions on smoking in the
home, school, and community settings.home, school, and community settings.
Number of cigarettes smoked, frequency ofNumber of cigarettes smoked, frequency of
smoking, self-efficacy to refuse offers, peersmoking, self-efficacy to refuse offers, peer
support for smoking, and other problem behaviors.support for smoking, and other problem behaviors.
Stages of Smoking Onset andStages of Smoking Onset and
Predictive Factors among YouthPredictive Factors among Youth

13. It is essential that clinicians andIt is essential that clinicians and
health care delivery systemshealth care delivery systems
(including administrators,(including administrators,
insurers, and purchasers)insurers, and purchasers)
institutionalize the consistentinstitutionalize the consistent
identification, documentation,identification, documentation,
and treatment of every tobaccoand treatment of every tobacco
user seen in a health careuser seen in a health care
setting.setting.

14. Brief tobacco dependenceBrief tobacco dependence
treatment is effective, andtreatment is effective, and
every patient who usesevery patient who uses
tobacco should be offeredtobacco should be offered
at least brief treatment.at least brief treatment.

15. Assessment of Tobacco UseAssessment of Tobacco Use
Does Patient Now Use
Tobacco?
Did Patient
Once Use?
Tobacco?
Prevent
Relapse
Promote
Motivation
To Quit
Provide
Appropriate
Treatments
Is Patient Now
Willing To Quit?
Encourage
Continued
Abstinence
YES NO
YES NO YES NO
Patient Presents to a
Health Care Setting

16. Two Questions, Three MinutesTwo Questions, Three Minutes
Very Brief CounselingVery Brief Counseling
 Do you smoke?Do you smoke?
 Do you want to quit?Do you want to quit?
 If yes-If yes-
 provide adviceprovide advice
 set quit dateset quit date
 prescribe medsprescribe meds
 set follow-upset follow-up
 If no-provide advice and move onIf no-provide advice and move on

17. PharmacotherapiesPharmacotherapies
Numerous effective pharmacotherapies forNumerous effective pharmacotherapies for
smoking cessation now exist. Except insmoking cessation now exist. Except in
the presence of contraindications, thesethe presence of contraindications, these
should be used with all patientsshould be used with all patients
attempting to quit smoking.attempting to quit smoking.
SixSix first-linefirst-line pharmacotherapies werepharmacotherapies were
identified that reliably increase long-termidentified that reliably increase long-term
smoking abstinence rates:smoking abstinence rates:
Bupropion SRBupropion SR • Nicotine Nasal Spray• Nicotine Nasal Spray
Nicotine GumNicotine Gum • Nicotine Patch• Nicotine Patch
Nicotine InhalerNicotine Inhaler Nicotine LozengeNicotine Lozenge

18. The “5 R’s” to EnhanceThe “5 R’s” to Enhance
Motivation for Patients UnwillingMotivation for Patients Unwilling
To QuitTo Quit
 RELEVANCERELEVANCE: Tailor advice and discussion to: Tailor advice and discussion to
each patienteach patient
 RISKSRISKS: Discuss risks of continued smoking: Discuss risks of continued smoking
 REWARDSREWARDS: Discuss benefits of quitting: Discuss benefits of quitting
 ROADBLOCKSROADBLOCKS: Identify barriers to quitting: Identify barriers to quitting
 REPETITIONREPETITION: Reinforce the motivational: Reinforce the motivational
message at every visitmessage at every visit

19. Types of Prevention ProgramsTypes of Prevention Programs
for Youthfor Youth
School-based curriculaSchool-based curricula
School environmental changesSchool environmental changes
Parental involvementParental involvement
Teen cessation programsTeen cessation programs
Social and commercial access strategiesSocial and commercial access strategies
Mass media campaignsMass media campaigns
Cigarette advertising and promotional bansCigarette advertising and promotional bans
Price increasesPrice increases

20. Sources of MOST RECENT Cigarette:Sources of MOST RECENT Cigarette:
Past Month Smokers, Grades 8-10Past Month Smokers, Grades 8-10
N = 3991N = 3991Source: Forster et al, under review.

21. Mass Media StrategiesMass Media Strategies
Aimed at YouthAimed at Youth
Pros Cons
Reach large numbersReach large numbers
of teensof teens
Can change socialCan change social
normsnorms
Can be linked to moreCan be linked to more
intensive interventionsintensive interventions
Message may not beMessage may not be
relevantrelevant
Superficial preventionSuperficial prevention
messagemessage
Expensive on primaryExpensive on primary
networksnetworks
Needs frequent updatingNeeds frequent updating
Types:Types: Television counter-advertising, radio ads,Television counter-advertising, radio ads,
print media, internetprint media, internet

22. Tobacco Advertising ContinuesTobacco Advertising Continues
in Youth-Oriented Magazinesin Youth-Oriented Magazines

23. Thank you forThank you for
NOT SmokingNOT Smoking