Tobacco Use and It’s Impact Tobacco Use and It’s Impact on Diabeteson Diabetes

Peggy Bourgeois, APRN, MN, CNS, CDE Peggy Bourgeois, APRN, MN, CNS, CDE

PBB Associates, LLCPBB Associates, LLC

Diabetes MellitusDiabetes MellitusScope of ProblemScope of Problem

Affects 20.8 million AmericansAffects 20.8 million Americans

Affects many areas of the bodyAffects many areas of the body

New therapies can prevent and/or New therapies can prevent and/or delay complicationsdelay complications

Diabetes PrevalenceDiabetes Prevalence

LOUISIANA DIABETES STATISTICSLOUISIANA DIABETES STATISTICS

Approximately 274,000 adults or seven percent of adults in Louisiana Approximately 274,000 adults or seven percent of adults in Louisiana have been diagnosed with diabetes (BRFSS, 2004)have been diagnosed with diabetes (BRFSS, 2004)

African Americans have the highest prevalence of diabetes, with a 10.9% African Americans have the highest prevalence of diabetes, with a 10.9% diagnosis rate, compared to 7.9% of Hispanics and 7% of the white diagnosis rate, compared to 7.9% of Hispanics and 7% of the white population (BRFSS, 2004)population (BRFSS, 2004)

As of 1996, Louisiana had the highest death rate due to diabetes (32.5 As of 1996, Louisiana had the highest death rate due to diabetes (32.5 per 100,00) of all the other U.S. states. The national death rate due to per 100,00) of all the other U.S. states. The national death rate due to diabetes is 18.5 per 100,000diabetes is 18.5 per 100,000

In 2002, diabetes was the cause of 3,190 deaths, approximately 830 In 2002, diabetes was the cause of 3,190 deaths, approximately 830 (26%) listed cardiovascular disease as an underlying cause(26%) listed cardiovascular disease as an underlying cause

In 2001, the total cost of hospital discharges for people with diabetes in In 2001, the total cost of hospital discharges for people with diabetes in Louisiana was approximately $1.5 billion dollars (LAHIDD, 2001)Louisiana was approximately $1.5 billion dollars (LAHIDD, 2001)

DiabetesDiabetesDefinitionDefinition

A chronic illness in which the body A chronic illness in which the body lackslacks insulin insulin oror is is resistantresistant to insulin to insulin

Multiple hormones play a role in glucose Multiple hormones play a role in glucose regulation regulation

Classifications Diabetes MellitusClassifications Diabetes Mellitus

Type 1 (absolute insulin deficiency)Type 1 (absolute insulin deficiency)– Idiopathic Idiopathic – Immune-MediatedImmune-Mediated

Type 2 (insulin resistance)Type 2 (insulin resistance)– Relative insulin deficiencyRelative insulin deficiency– Deficient insulin secretionDeficient insulin secretion

Impaired Fasting Glucose (IFG)Impaired Fasting Glucose (IFG)Impaired Glucose Tolerance (IGT)Impaired Glucose Tolerance (IGT)Gestational Diabetes (GDM)Gestational Diabetes (GDM)

Diagnostic Criteria Diabetes Diagnostic Criteria Diabetes

FPG FPG >>126 mg/dl on 2 occasions 126 mg/dl on 2 occasions

Casual glucose Casual glucose >>200 mg/dl with 200 mg/dl with symptoms symptoms

IFG: Fasting IFG: Fasting >>100 and < 126 mg/dl 100 and < 126 mg/dl (Pre – diabetes) (Pre – diabetes)

IGT: 2 hr PG IGT: 2 hr PG >>140 and < 200 mg/dl140 and < 200 mg/dl

Normal MetabolismNormal MetabolismInsulinInsulin

Secreted by beta cells of pancreasSecreted by beta cells of pancreas

Allows glucose to enter cells Allows glucose to enter cells

Allows glucose to enter liverAllows glucose to enter liver

Prevents release of liver glycogenPrevents release of liver glycogen

Prevents fat breakdownPrevents fat breakdown

Stores excess calories as fatStores excess calories as fat

Normal Insulin ReleaseNormal Insulin ReleaseNon-diabetic never stops making insulinNon-diabetic never stops making insulin

Meal Meal Meal

Insulin bolus occurs in the first 10 minutes after eating

Basal insulin is released every 12 minutes

Problems in type 1 DiabetesProblems in type 1 Diabetes

Generally less than 40 yearsGenerally less than 40 yearsNo insulin, must be given by No insulin, must be given by injectioninjectionNo amylin (must be given by No amylin (must be given by injection)injection)Ketone proneKetone proneAutoimmune diseaseAutoimmune disease

Metabolic Syndrome or Pre DiabetesMetabolic Syndrome or Pre DiabetesAKA Syndrome XAKA Syndrome X

Progression of type 2 DiabetesProgression of type 2 Diabetes

Insulin ResistanceInsulin ResistanceHepatic Glucose ProductionHepatic Glucose Production

Insulin Production (Insulin Production (-cell failure)

Postprandial Blood GlucosePostprandial Blood Glucose

Fasting Blood GlucoseFasting Blood Glucose

Typical Diagnosis of type 2 DiabetesTypical Diagnosis of type 2 Diabetes

Impaired Glucose Impaired Glucose ToleranceTolerance Frank DiabetesFrank Diabetes

Years Years to to

DecadeDecadess

TimeTime

Hyperinsulinproduction

Normal

Diabetes Screening – Type 2Diabetes Screening – Type 2ADA recommends screening for diabetes & ADA recommends screening for diabetes & pre diabetespre diabetesHigh risk, asymptomatic adultsHigh risk, asymptomatic adults

> 45 years> 45 yearsBMI BMI >> 25 25 Younger if there are other risk factorsYounger if there are other risk factors

Fasting or 2-h OGTT (75 gm carb)Fasting or 2-h OGTT (75 gm carb) Fasting less expensive, shows pre-diabetesFasting less expensive, shows pre-diabetes OGTT shows IGTOGTT shows IGT

If normal repeat every 3 yearsIf normal repeat every 3 years

Diabetes Screening ChildrenDiabetes Screening Children

Test FPG at age 10 or puberty w/ these Test FPG at age 10 or puberty w/ these criteria:criteria:

BMI > 85BMI > 85thth percentile percentile for age & sexfor age & sex weight for height orweight for height or weight > 120% ideal for heightweight > 120% ideal for height

Plus 2 additional risk factorsPlus 2 additional risk factors family history type 2family history type 2 Race/ethnicityRace/ethnicity Signs of insulin resistanceSigns of insulin resistance

Repeat every 2 yearsRepeat every 2 years

Complications of DMComplications of DM

ESRD-new cases:32%

Retinopathy: 14-40%

Foot/Leg Amputations:50%

Heart Disease: >400%

Stroke: >200%

American Diabetes AssociationAmerican Diabetes Association

Tobacco has many bad health effects, Tobacco has many bad health effects, particularly for people with diabetesparticularly for people with diabetesNo matter how long you've smoked, your No matter how long you've smoked, your health will improve after you quithealth will improve after you quitNicotine is one of the most addictive Nicotine is one of the most addictive substances knownsubstances known

Physical addictionPhysical addictionBecome psychologically hooked on cigarettes Become psychologically hooked on cigarettes Kicking the habit is hard - but worth the workKicking the habit is hard - but worth the work

Smoking Hurts Your Health Smoking Hurts Your Health

Smoking is best-known for causing cancer Smoking is best-known for causing cancer aggravates heart and blood vessel aggravates heart and blood vessel disease in people with diabetesdisease in people with diabetes

Decrease the amount of oxygen to tissues leading to Decrease the amount of oxygen to tissues leading to heart attack, stroke, miscarriage, or stillbirthheart attack, stroke, miscarriage, or stillbirth

Increases cholesterol levels and the levels of other Increases cholesterol levels and the levels of other fats increasing the risk of heart attack fats increasing the risk of heart attack

Smoking increases blood pressureSmoking increases blood pressure

Damages and constricts the blood vessels. This Damages and constricts the blood vessels. This damage can worsen foot ulcers and lead to blood damage can worsen foot ulcers and lead to blood vessel disease and leg and foot infectionsvessel disease and leg and foot infections

American Diabetes Association; “Smoking”, www.diabetes.org

SmokingSmokingSmokers with diabetes are more likely to get nerve Smokers with diabetes are more likely to get nerve damage and kidney diseasedamage and kidney disease

Smokers get colds and respiratory infections easierSmokers get colds and respiratory infections easier

Smoking increases risk for limited joint mobilitySmoking increases risk for limited joint mobility

Smoking can cause cancer of the mouth, throat, lung, Smoking can cause cancer of the mouth, throat, lung, and bladderand bladder

People with diabetes who smoke are three times as People with diabetes who smoke are three times as likely to die of cardiovascular disease as are other likely to die of cardiovascular disease as are other people with diabetespeople with diabetes

Smoking raises blood sugar level, making it harder to Smoking raises blood sugar level, making it harder to controlcontrol

Smoking can cause impotenceSmoking can cause impotence

American Diabetes Association; “Smoking”, www.diabetes.org

Position StatementPosition Statement

Health care professionals should emphasize smoking

cessation as a priority of state-of-the-art care for all

diabetic smokers

LOUISIANA TOBACCO LOUISIANA TOBACCO STATISTICSSTATISTICS

Tobacco use is the single most preventable cause of death and Tobacco use is the single most preventable cause of death and disability causing more deaths every year that AIDS, alcohol, disability causing more deaths every year that AIDS, alcohol, car crashes, murders, suicides, and illegal drugs combined. car crashes, murders, suicides, and illegal drugs combined.

Cigarette smoking was the leading risk factor for disease, Cigarette smoking was the leading risk factor for disease, responsible for an estimated 6,427 deaths and 96,085 years of responsible for an estimated 6,427 deaths and 96,085 years of potential years of life lost in 1999. potential years of life lost in 1999.

Cigarette smoking is responsible for one in four deaths due to Cigarette smoking is responsible for one in four deaths due to cardiovascular disease and contributes to illness and death cardiovascular disease and contributes to illness and death due to cancers, respiratory diseases, premature and low birth due to cancers, respiratory diseases, premature and low birth weight infants, sudden infant death syndrome, and burns. weight infants, sudden infant death syndrome, and burns.

More than 750,000 adults (24.6%), 79,000 high school, and More than 750,000 adults (24.6%), 79,000 high school, and 28,000 (17.1%) middle school aged children in Louisiana 28,000 (17.1%) middle school aged children in Louisiana currently smoke cigarettes. currently smoke cigarettes.

Louisiana Youth Tobacco Survey, Tobacco Control Program, 2002

LOUISIANA TOBACCO LOUISIANA TOBACCO STATISTICSSTATISTICS

Nine out of ten current smokers started before they were 18 Nine out of ten current smokers started before they were 18 years of age. years of age.

15.7% of the adult population in Louisiana has used 15.7% of the adult population in Louisiana has used smokeless tobacco products such as chewing tobacco, dip, smokeless tobacco products such as chewing tobacco, dip, or snuff at some point in their lives. or snuff at some point in their lives.

Individuals: Individuals: in the 18-44 year age groupin the 18-44 year age groupWith an annual household income less than $25,000 With an annual household income less than $25,000 Individuals with less than a high school educationIndividuals with less than a high school educationAfrican Americans were more likely to report that they are being African Americans were more likely to report that they are being exposed to second-hand smoke at their place of work. exposed to second-hand smoke at their place of work.

The total cost during 1999 for Louisiana that was attributable The total cost during 1999 for Louisiana that was attributable to cigarette smoking was estimated at $2.81 billion.to cigarette smoking was estimated at $2.81 billion.

Smokers not only put their own lives at risk, but also affect Smokers not only put their own lives at risk, but also affect the lives of people around them.the lives of people around them.

Public Health Service (PHS) Public Health Service (PHS) Clinical Practice Guideline for Clinical Practice Guideline for Teaching Tobacco Use and Teaching Tobacco Use and

DependenceDependenceEstablished the “5 A’s” of interventionEstablished the “5 A’s” of intervention

1.1. AskAsk

2.2. AdviseAdvise

3.3. AssessAssess

4.4. AssistAssist

5.5. ArrangeArrange

ASKASK

History of tobacco useHistory of tobacco useAdolescent and Adult with diabetesAdolescent and Adult with diabetesPregnancy – use multiple choice questionsPregnancy – use multiple choice questions

Which of the following best describes your tobacco use?Which of the following best describes your tobacco use? I use tobacco regularly now, about the same as I use tobacco regularly now, about the same as

before becoming pregnantbefore becoming pregnant I use tobacco regularly now, but have cut down since I use tobacco regularly now, but have cut down since

I found out I was pregnantI found out I was pregnant I use tobacco every once in a whileI use tobacco every once in a while I have quit using tobacco since finding out I was I have quit using tobacco since finding out I was

pregnantpregnant I have never used tobacco.I have never used tobacco.

Psychologically, fear of harming the babyPsychologically, fear of harming the baby

Former tobacco users should be offered short term Former tobacco users should be offered short term relapse prevention interventionrelapse prevention intervention

ADVISEADVISE

Advise to quit should be clear, strong and Advise to quit should be clear, strong and personalized to the individual’s own personalized to the individual’s own situation.situation.

Prevention of diabetes complicationsPrevention of diabetes complications

Effects of second hand smoke on the Effects of second hand smoke on the familyfamily

Monetary cost of smokingMonetary cost of smoking

ASSESSASSESS

““Are you willing to try to quit at this time?”Are you willing to try to quit at this time?”

What if they are not willing to stop?What if they are not willing to stop?No desire to stopNo desire to stop

Fear they will be unable to stopFear they will be unable to stop

Fear withdrawalsFear withdrawals

Fear weight gainFear weight gain

Offer the “5 R’s” Offer the “5 R’s”

ASSISTASSIST

The patient is willing to quit: HOW to quit.The patient is willing to quit: HOW to quit.

1.1. Set a quit date - within two weeks is best.Set a quit date - within two weeks is best.

2.2. Tell family and friends. Tell family and friends. Social support helps!Social support helps!

3.3. Review past quit attempt experiences. Review past quit attempt experiences. What worked? What worked?

What didn’t?What didn’t?

ASSISTASSIST4.4. Anticipate challenges. Symptoms: Anticipate challenges. Symptoms:

Irritability Irritability

cravings cravings

InsomniaInsomnia

coughing may occur for 2-3 weeks after quittingcoughing may occur for 2-3 weeks after quitting

5.5. Encourage adult patients attempting to quit to utilize Encourage adult patients attempting to quit to utilize effective pharmacotherapies for tobacco effective pharmacotherapies for tobacco dependence treatment i.e., >10 / day, other medical dependence treatment i.e., >10 / day, other medical constraints, pregnant/breastfeeding, adolescents constraints, pregnant/breastfeeding, adolescents exceptexcept in special circumstances in special circumstances

6.6. Refer to an intensive counseling serviceRefer to an intensive counseling service

ARRANGEARRANGESchedule follow-up in person or on the Schedule follow-up in person or on the phonephone

Should occur within the first week after the Should occur within the first week after the quit datequit date

Provide with relapse prevention informationProvide with relapse prevention information

If already relapsed: If already relapsed: Consistent with the chronic nature of tobacco Consistent with the chronic nature of tobacco dependencedependence

Not a sign of personal failureNot a sign of personal failure

Set a new quit date and revise his/her quit planSet a new quit date and revise his/her quit plan

THE “5 R’s”THE “5 R’s”

1.1. RELEVANCE: RELEVANCE: Why quitting is important to their own Why quitting is important to their own personal situationpersonal situation

2.2. RISKS:RISKS:Outline the risks of continued tobacco useOutline the risks of continued tobacco use

3.3. REWARDS:REWARDS:Outline the Benefits of quittingOutline the Benefits of quitting

THE “5 R’s”THE “5 R’s”

4.4. ROADBLOCKS:ROADBLOCKS:What are the barriers preventing this person What are the barriers preventing this person from quitting? from quitting?

What are some solutions to these barriers?What are some solutions to these barriers?

5.5. REPETITION:REPETITION:Repeat this discussion frequently, until the Repeat this discussion frequently, until the person is ready to quit.person is ready to quit.

Why is Quitting So Hard?Why is Quitting So Hard?

People smoke for two reasons. People smoke for two reasons. Nicotine is highly addictive. Nicotine is highly addictive.

Withdrawal Withdrawal

Symptoms include: irritable, sweating, headaches, Symptoms include: irritable, sweating, headaches, diarrhea, or constipation, feeling restless, tired, or diarrhea, or constipation, feeling restless, tired, or dizzy. dizzy.

Is usually worst on the second day and gradually Is usually worst on the second day and gradually lessens with time.lessens with time.

““But it’s so hard to quit!”But it’s so hard to quit!”Second, Second,

Many become psychologically tied to Many become psychologically tied to smoking. smoking.

Part of daily ritual Part of daily ritual

Helps them wake up in the morning Helps them wake up in the morning

Comforts them when they are upset, and Comforts them when they are upset, and

Rewards them for a job well done Rewards them for a job well done

Smoking also has pleasurable physical effects Smoking also has pleasurable physical effects – It relaxes people and perks them up. It relaxes people and perks them up.

StressStressStress can alter blood glucose levelsStress can alter blood glucose levels

May not take care of themselvesMay not take care of themselvesIncrease smoking, alcohol consumption, less exerciseIncrease smoking, alcohol consumption, less exercise

Stress hormones may also alter blood glucose levelsStress hormones may also alter blood glucose levelsIn type 1 diabetes response is more mixedIn type 1 diabetes response is more mixed

While most people's glucose levels go up with mental stress, While most people's glucose levels go up with mental stress, others' glucose levels go down. others' glucose levels go down.

In people with type 2 diabetes, mental stress often In people with type 2 diabetes, mental stress often raises blood glucose levelsraises blood glucose levels

Physical stress, illness or injury, causes higher Physical stress, illness or injury, causes higher blood glucose levels in people with either type of blood glucose levels in people with either type of diabetes. diabetes.

StressStress

Stress blocks the body from releasing Stress blocks the body from releasing insulin in people with type 2 diabetes insulin in people with type 2 diabetes

People with type 2 diabetes may also be more People with type 2 diabetes may also be more sensitive to some of the stress hormonessensitive to some of the stress hormones

Stress reduction doesn't have this effect in Stress reduction doesn't have this effect in type 1 diabetestype 1 diabetes

Preparing to Quit Preparing to Quit Study your own smoking habits Study your own smoking habits

What events or activities make you light up? What events or activities make you light up? How often do you smoke? How often do you smoke?

Look for replacements for smokingLook for replacements for smokingLearn and practice another way to relaxLearn and practice another way to relaxDeep breathing and relaxation exercisesDeep breathing and relaxation exercisesStand and stretch exercises Stand and stretch exercises Walk - Exercise makes you more alertWalk - Exercise makes you more alert

Set a date to quitSet a date to quit

Barriers to CessationBarriers to CessationPrevalence of smoking not much different as Prevalence of smoking not much different as that of the population at large. that of the population at large. Minimal information available for diabetic Minimal information available for diabetic smokers.smokers.

Suggests the patients don’t do wellSuggests the patients don’t do well

Weight gainWeight gainPerceived as less important than avoiding sweets, Perceived as less important than avoiding sweets, limiting alcohol consumption and several other limiting alcohol consumption and several other health behaviorshealth behaviorsLow priorityLow priority

Guidelines for Reducing Guidelines for Reducing BarriersBarriers

Ensure intensive counselingEnsure intensive counseling

Stress the specific role of tobacco in Stress the specific role of tobacco in diabetes complicationsdiabetes complications

Plan for and limit weight gainPlan for and limit weight gain

Look for and treat depression.Look for and treat depression.

Find safe, tobacco-free coping methods to Find safe, tobacco-free coping methods to deal with diabetes related stressorsdeal with diabetes related stressors

Learning to Relax Learning to Relax Breathing exercisesBreathing exercises. Sit or lie down, uncross legs . Sit or lie down, uncross legs and arms. Take in a deep breath. Push out as much and arms. Take in a deep breath. Push out as much air as you can. Breathe in and out again, this time air as you can. Breathe in and out again, this time relax muscles on purpose while breathing out. Keep relax muscles on purpose while breathing out. Keep breathing and relaxing for 5 to 20 minutes at a time. breathing and relaxing for 5 to 20 minutes at a time. Do the breathing exercises at least once a day. Do the breathing exercises at least once a day.

Progressive relaxation therapyProgressive relaxation therapy. In this technique, . In this technique, you learn in a clinic or from an audio tape, to tense you learn in a clinic or from an audio tape, to tense and relax musclesand relax muscles

ExerciseExercise. Relax your body by moving through a wide . Relax your body by moving through a wide range of motion. Three ways to loosen up through range of motion. Three ways to loosen up through movement are circling, stretching, and shaking parts of movement are circling, stretching, and shaking parts of body. To make this exercise more fun, move with body. To make this exercise more fun, move with music.music.

Learning to Relax Learning to Relax

Replace bad thoughts with good onesReplace bad thoughts with good ones. Each . Each time you notice a bad thought, purposefully think time you notice a bad thought, purposefully think of something that makes you happy or proud. Or of something that makes you happy or proud. Or memorize a poem, prayer, or quote and use it to memorize a poem, prayer, or quote and use it to replace a bad thought. replace a bad thought.

Whatever method you choose to relax, practice Whatever method you choose to relax, practice it. Just as it takes weeks or months of practice to it. Just as it takes weeks or months of practice to learn a new sport, it takes practice to learn learn a new sport, it takes practice to learn relaxation. relaxation.

Tobacco Use and Diabetes Tobacco Use and Diabetes ComplicationsComplications

Tobacco raises blood glucoseTobacco raises blood glucoseNicotine and other products in tobacco smoke Nicotine and other products in tobacco smoke inhibit the action of insulin.inhibit the action of insulin.

Chewing tobacco is high in sugarChewing tobacco is high in sugar

Increases retinopathyIncreases retinopathy

Greater chance of developing gum disease Greater chance of developing gum disease and tooth loss.and tooth loss.

Increases nerve damage - nephropathyIncreases nerve damage - nephropathy

Tobacco Use and Diabetes Tobacco Use and Diabetes ComplicationsComplications

Erectile dysfunctionErectile dysfunction

More likely to have a heart attack and 3x’s More likely to have a heart attack and 3x’s more likely to die of a heart diseasemore likely to die of a heart disease

Smoking triples the chance of developing Smoking triples the chance of developing kidney disease in people without diabeteskidney disease in people without diabetes

Below the knee amputations common in Below the knee amputations common in smokers.smokers.

Weight GainWeight Gain

Nicotine increases metabolismNicotine increases metabolismCauses body tensionCauses body tensionAccelerates heart rateAccelerates heart rateIncrease blood pressureIncrease blood pressurePhysical agitationPhysical agitation

Quitters gain 3-5 #’s due to water retention Quitters gain 3-5 #’s due to water retention during the first week after quittingduring the first week after quitting

Tobacco reduces the ability to smell, food is Tobacco reduces the ability to smell, food is more appealing when they quit smokingmore appealing when they quit smoking

Hands to face habit – increased eatingHands to face habit – increased eatingCravings for cigarettes or chewing confused as Cravings for cigarettes or chewing confused as hungerhunger

Increase physical activityIncrease physical activity

Gradually improve eating habitsGradually improve eating habits

Replace smoking with healthy activitiesReplace smoking with healthy activities

Drink fluids, especially water – avoid caffeinated Drink fluids, especially water – avoid caffeinated beveragesbeverages

Get enough sleepGet enough sleep

Lifetime history of clinical depression are about half Lifetime history of clinical depression are about half as likely to succeed as likely to succeed

People with diabetes are at greater risk for People with diabetes are at greater risk for depression depression

Healthy Ways to Minimize Healthy Ways to Minimize Weight GainWeight Gain

Medications to Help Quit Medications to Help Quit SmokingSmoking

Type Type Common namesCommon names Available viaAvailable via DescriptionDescription

Bupropion SRBupropion SR Wellbutrin® SR,Wellbutrin® SR,Zyban®Zyban®Budeprion™ SRBudeprion™ SR

prescriptionprescription Antidepressant that assists inAntidepressant that assists inrelieving withdrawal symptoms;relieving withdrawal symptoms;most effective when used inmost effective when used incombination with a supervisedcombination with a supervisedstop-smoking programstop-smoking program

Nicotine gumNicotine gum Nicorette®Nicorette® over-the-counterover-the-counter Chewable gum; most effectiveChewable gum; most effectivewhen used in combination with awhen used in combination with asupervised stop-smoking programsupervised stop-smoking program

Nicotine nasal Nicotine nasal sprayspray

Nicotrol® NSNicotrol® NS prescriptionprescription Nasal spray; most effective whenNasal spray; most effective whenUsed in combination with aUsed in combination with asupervised stop-smoking programsupervised stop-smoking program

Nicotine patchNicotine patch Nicotrol®Nicotrol®Prostep®Prostep®Habitrol® Habitrol® Nicoderm®Nicoderm®

prescription and prescription and overover

the-counterthe-counter

Skin patch; most effective when Skin patch; most effective when used in combination with aused in combination with asupervised stop smoking programsupervised stop smoking program

STOP SMOKING PROGRAMSSTOP SMOKING PROGRAMS

The Great American SmokeoutThe Great American SmokeoutAmerican Cancer SocietyAmerican Cancer SocietyFood and FitnessFood and FitnessThe American Lung Association The American Lung Association Positive Thinking Positive Thinking Why Quit? Why Quit? You Can Quit SmokingYou Can Quit Smoking Helpful Tips to Kick the Smoking Habit Helpful Tips to Kick the Smoking Habit

LA REPORT CARD - 2006LA REPORT CARD - 2006

Grades:   Grades:   

Smokefree AirSmokefree Air A    A    

Youth AccessYouth Access FF

Tobacco PreventionTobacco Prevention

& Control Spending & Control Spending FF

Cigarette TaxCigarette Tax FF

PHS GuidelinePHS Guideline

““Smokers with comorbid psychiatric Smokers with comorbid psychiatric conditions should be provided smoking conditions should be provided smoking cessation treatments identified as cessation treatments identified as effective … although psychiatric effective … although psychiatric comorbidity places smokers at comorbidity places smokers at increased risk from relapse, such increased risk from relapse, such smokers can be helped by smoking smokers can be helped by smoking cessation treatments.”cessation treatments.”

Helping Patients with Diabetes Quit Using Helping Patients with Diabetes Quit Using TobaccoTobacco

Guideline for Treating Tobacco Use and Guideline for Treating Tobacco Use and DependenceDependence

November 2003November 2003

Thank YouThank You

peggyboo1@cox.netpeggyboo1@cox.net