Clinical A Opportunities Guide for for Smoking the Busy Intervention Physician EEEEEEEEEEEEEEEEEEEEEE AAAAAAAAAAAAAAAA Public Health Service National Inst tttttttt PUJLIC HEALTH Ubki-k» irERKElEY \ kUBRARY \ UN1VERSITY CE :W Opportuni 'es For Smoking Intervenlion A Guide for the Busy Physician National Heart, Lung, and Blood Institute Smoking Education Program National Institutes of Health Bethesda, Maryland 20892 In cooperation with: The American Lung Association and its medical section, The American Thoracic Society U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service National Institutes of Health NIH Publication No. 86—2178 . ,7 , August 1986 L Vulrw ‘ For sale by the Superintendent of Documents, U .8. Government Printing Office Washington, DC. 20402 7334152525? PMISL. — Table of Contents Foreword 1 Introduction 2 Smoking Cessation: What Can You Expect From Patients? 2 Smoking Interventions: What You Can Do 2 Clinical Opportunities to Talk About Smoking With Patients 4 1. Act as a Role Model by Not Smoking 4 2. Provide Information on Risks Associated with Smoking and Reduction of Risk if the Patient Stops 4 3. Encourage Abstinence by Direct Advice and Suggestions 5 . Refer Patient to a Smoking Cessation Program 6 4 5. Follow Up on Use of Specific Cessation and Maintenance Strategies 6 Biomedical Consequences of Smoking The Pathophysiologic Effects of Cigarette Smoke on the Pulmonary System 9 The Pathophysiologic Effects of Cigarette Smoke on the Cardiovascular System 12 Smoking and Other Clinical Situations 15 The Effects of Smoking on Clinical Test Results 16 How Smoking May Interfere with Drug Therapy 16 Smoking Intervention Information and Resources How to Recognize Tobacco Dependence 19 Common Causes of Relapse 19 The Nicotine Withdrawal Syndrome 19 Seven Steps to Prevent Relapse 19 Patient Smoking Profile 21 Personal Advice About Smoking 23 Responses to Common Patient Rationalizations 26 Medical Practice Protocol Overview for Smoking Intervention 27 Smoking Cessation Resources 29 Bibliography 31 Foreword As the primary health care providers for most Americans, physicians can play an important role in helping their patients stop smoking. Estimates show that if physicians delivered stop—smok— ing messages to their patients as a routine part of physician office visits, at least 38 million smokers could be reached annually. When viewed from this perspective, physicians have an exciting opportunity to help their patients live healthier lives. The National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NlH),* the American Lung Association (ALA), and its medical section, the American Thoracic Society (ATS), have devel— oped this resource to help physicians take advantage of the many oppor- tunities they have in their day-to—day practice to provide credible health information to patients. *The National Institutes of Health is one of the primary Public Health Service components of the Department of Health and Human Services. This guide highlights the clinical opportunities that are available to the physician and to other personnel in the physician's office to reduce smok- ing—related cardiovascular and lung disease. It describes how physicians can encourage patients to stop smok— ing in ways that are consistent with their medical practice protocol. The kinds of interventions that are described can be easily integrated into a physician's clinical setting—they easily fit into an office format. However, while physicians may initiate smoking cessation actions, they are not the patient’s only source of support in making this complex behavior change. At the community level, a variety of public and voluntary health initiatives can provide practitioners with resources to expand and reinforce their patient counseling W46 C. Everett Koop, MD Surgeon General US. Public Health Service Kenneth M. Moser, MD. President, American Thoracic Society efforts. At the national level, the broad-based smoking cessation effort involves many public and professional education activities focused on the Surgeon General’s goal of a smoke- free society by the year 2000. Cigarette smoking is a major cause of chronic obstructive pulmonary disease, cardiovascular disease, and a variety of cancers. It remains the largest avoidable cause of death and disability in the United States. Physicians can play a powerful role in promoting long-term nonsmoking behavior with their patients and ultimately create a healthier America. Claude Lenfant, MD. Director, National Heart, Lung, and Blood Institute 0‘ James A. SwomIey Managing Director, American Lung Association Introduction Despite the fact that 20 years have elapsed since the first Surgeon General's Report on the Health Con— sequences of Smoking, Americans continue to smoke in epidemic pro- portions. Smoking is one of the major public health hazards in our Nation today, and results in over 300,000 tobacco—related deaths each year. Over 50 million Americans smoke, and many of them smoke heavily. Heavy smokers have the highest risk of developing tobacco-related dis— eases, but they are also the ones who find it hardest to quit. Studies suggest that up to 70 per- cent of current smokers would be more likely to quit if they were encour— aged to do so by their physicians. Even minimal stop—smoking interven- tions by physicians—who are seen as the most credible sources of health information—can make an important difference in whether people stop smoking. As a physician, no matter what your specialty, you have patients who are high risk smokers and you have many clinical opportunities to talk about how smoking affects their health. Whether a patient is coming to you for a pulmonary problem, a heart condition, a routine physical, or any other reason, the fact that he or she smokes may affect your diagnosis and even the prognosis for a disease. It is important for you, as the physician, to discuss the patient's smoking and make it clear that smoking directly affects his or her health. You may also want to tell the patient that the treatment plan will be influenced by whether he or she continues or stops smoking. By taking advantage of each clinical opportunity to relate the adverse consequences of smoking and the benefits of quitting to the patient's condition, you increase the likelihood that your patient will decide to give up tobacco for good. Smoking Cessation: What Can You Expect From Patients? Smoking Interventions: What You Can Do Studies of the effectiveness of physi- cian smoking intervention indicate that advice alone can have a signifi- cant impact on smoking behavior. As might be expected, such advice has a greater impact on patients who are at high risk of or who have been diag— nosed with a tobacco—related disease. By combining advice with referral to group programs or suggesting self- help materials, you may do consider— ably better than these general results. Some Facts About Smokers Each year, 3.3 million people stop smoking. Most smokers: 0 Are concerned about the per— sonal health consequences of smoking. 0 Want to quit. 0 Are more likely to be influenced to quit if their physician recommends it. 0 Prefer self—help to group programs. 0 See a physician at least once a year. (An estimated 38 million of over 50 million US. adults who smoke could be reached annu- ally with a smoking cessation message from a physician.) A physician can promote smoking cessation in several ways:* 1. Act as a role model by not smoking and creating a nonsmoking environment. 2. Provide information on risks associated with smoking and reduction of risk if the patient stops. 3. Encourage abstinence by direct advice and suggestions. 4. Refer the patient to a smoking cessation program. 5. Prescribe and follow up on use of specific cessation and maintenance strategies. *Souroe: Lichtenstein, E., Danaher, B.G.: "What can the physician do to assist the patient to stop smoking?” COLD: C11'n1'ca1 Treatment and Management, St. Louis, Mosby, 1978. - Questionnaire, physician advice, leaflet, and followup Questionnaire and - physician advice 1 _ Smoking (no intervention) Russell, M.A.Hi, Wilson, C., Taylor, C., Baker, C.D.: "Effect of general practitioners’ advice against smoking." British Medical Journal 22317235, 1979. 80- llghlllkl’allonm 60— 40- 20— Quit rate after one year (0/0 of patients) N 0 Advice Standard Intensive advice advice advice Rose, G., Hamilton, 13.1.5.2 ”A randomized Burt, A., lllingworth, D, Shaw, PRU, et al.: controlled trial of the effect on middle- ”Stopping smoking after myocardial aged men of advice to stop smoking." infarction.” Lancet 1:304-306, 1974. Journal of Epidemiology and Community Health 32(4):275-281, 1978. 1Study subjects were at high risk for cardiorespiratory disease. Clinical Opportunities to Talk About Smoking With Patients 1. Act as a Role Model by Not Smoking Symptoms 0 Cough 0 Sputum production 0 Shortness of breath Tests 0 Electrocardiography 0 Pulmonary function tests ' Total leukocyte counts 0 Blood pressure measurements Hematocrit Auscultation of heart and lungs Blood lipid studies Blood coagulation studies Serum alphal-antiprotease determinations Pregnancy tests 0 Carboxyhemoglobin determinations Diagnosis of Disease and Risk Factors 0 Coronary heart disease 0 Peripheral vascular disease 0 Angina pectoris 0 Hypertension 0 Emphysema 0 Chronic bronchitis 0 Pneumonia ' Asthma 0 Acute bronchitis 0 Recurrent respiratory infection 0 Diabetes mellitus 0 Hypercholesterolemia 0 Peptic ulcer 0 Allergy Drug Prescriptions 0 Drug/tobacco smoke interactions 0 Pharmacologic aids to smoking cessation —nicotine chewing gum Fortunater most physicians already serve as nonsmoking role models for their patients. Your office environment can also send a stop-smoking message to patients and help set the stage for the direct advice you give your patients. A few suggestions: 0 Adopt a no-smoking policy for your office staff. Studies show that a high proportion of nurses continue to smoke; your office policy could provide a strong motivation for them to stop. 0 Display ”No Smoking" signs or posters in your waiting room. 0 Remove ash trays from the waiting area. 0 Include pamphlets about the health effects of smoking and smoking cessation among your waiting room reading materials. 0 Keep video equipment in your waiting room and show tapes about the risks of smoking and how to stop. (See description of NHLBI film series, We Can't Go On Like This, page 29, and IN CONTROL: A Home Video FREEDOM FROM SMOKZNG® Program available from your local Lung Association.) Have your receptionist or nurse run tapes on a regular schedule. Provide Intonation on Risks Associated with Smoking andReductionoiiiiskiithePatientStops As you know, patients who stop smoking improve their prognosis for many illnesses. Continued smoking can interfere with the treatment of others. Patients need specific information about how their smoking affects their health and how their health might be improved if they stop smoking. We know that the range of serious smoking—related health problems is broad and includes pulmonary and cardiovascular diseases, cancer of several organ sites, complications in pregnancy, and reduced benefit from peptic ulcer treatment. But smoking can also have profound effects on diagnostic test results and on therapeutic drug absorption, metabolism, and action. In fact, when you are administering a test or conducting a routine procedure, you have an opportunity to educate your patient about the effects of smoking. For example, pulmonary function tests can graphically demonstrate damage from smoking and make a stop-smoking message personal and immediate. A diagnosis of hypertension also offers you an opportunity to point out that smoking magnifies the risk of other cardiovascular disease. The odds are high that some of the smokers you see will exhibit symptoms related to smoking. Nonsmokers who live with smokers may display symptoms, too, because of their passive or involuntary exposure to smoke. Children whose parents smoke, for example, have increased incidence of respiratory infection and asthma episodes. By motivating parents to stop smoking, pediatricians can reduce these problems. Studies also suggest that the parental role model is an important factor in a child’s decision to use or avoid cigarettes. 3. Encourage Abstinence by Blue! fidvlco and Suggesflons Probably the best ways you can encourage patients to stop smoking are direct advice and suggestiOns on how to quit. All smokers are not alike, and an approach that works for one person may not be appropriate for another. However, when you talk with your patients you should be brief, direct, unambiguous, and informative. What you tell patients about smoking should not be used as a ”scare tactic.” A more effective approach is to stress the positive health benefits that result from giving up smoking. The kind of smoking behavior your patient has and his or her feelings about quitting should influence the advice you give and the action steps you suggest. Some smokers, for example, may be heavily dependent on or addicted to nicotine and find it very difficult to stop even when they are highly motivated. The Fagerstrom Tolerance Scale may help you identify nicotine dependent smokers. This scale is included in the PATIENT SMOKING PROFILE which can be found in the Smoking Intervention Information and Resources section of the guide. Others, while not as physically dependent on cigarettes, remain unconvinced that the risks outweigh the pleasures of smoking. The age of a patient, too, may help shape your approach to smoking intervention. An adolescent is not likely to be influenced by a discussion of the long-term risks of smoking. But he or she may be motivated to quit if persuaded that smoking will have an effect on sports performance or social desirability. One behavioral step that is often recommended to help smokers quit is to set a quit-smoking date. While this can be effective, even smokers with an excellent quitting prognosis may be unwilling to make such a commitment. If the patient does not want to set a date, suggest that he or she take some other positive action within a specified time frame. For example, recommend that the patient contact a smoking-cessation program or think your message over and talk to you about it again. Approximately 60 percent of adult smokers have made at least one serious attempt to give up cigarettes, but have relapsed. Fortunately, a relapse does not necessarily spell the end of the efforts to quit. In fact, most smokers succeed only after making several attempts to quit. Smokers who have tried and failed to quit need to know this. There are a variety of reasons why people relapse, but usually you can anticipate and cope with most of them. It is important, for example, to tell patients that they may experience physical withdrawal symptoms when they first stop smoking. Knowing their symptoms are real and short-term can help patients get through this difficult time. A positive "can do" attitude seems to correlate with success in stopping smoking. Community and self—help cessation programs often focus on fostering such an attitude, and health professionals can use this approach, too. 4. Refer Fallen! lo a Smoking Cessation Program Once the patient is motivated to stop smoking, you will not need to provide the specific interventions to help him or her take successful action. Most communities now have effective behavioral programs to help smokers give up their habit. Self-help materials for smokers who want to quit on their own are also available through the American Lung Association’s nationwide affiliates. They have developed a video cassette program [IN CONTROL: A Home Video FREEDOM FROM SMOKING® Program] for use in physicians' offices or patients’ homes. This and other ALA self-help programs are described on page 30. The American Cancer Society's “Fresh Start" program is also available through their local offices around the country. Your community may sponsor other programs at hospitals, health departments, community health centers, and voluntary organizations such as the American Heart Association. You can use the form on page 29 to list the programs in your community so that you can provide directive, ”next-step" information for your patients. Follow Up on Use of Specific Mellon and Maintenance Strategies Patients who complete community programs or try to stop smoking on their own can benefit from physician advice that reinforces their program’s behavior change messages. Regardless of the stop—smoking strategy your patient follows, your continual support and encouragement are crucial. Followup is valuable to you as well as to the patient. It may be the only way you can learn the outcome of an effort to quit. For efficient followup: 0 Flag the charts of smokers and former smokers to remind yourself to ask about smoking at each visit. 0 Continue to give individual health messages to patients who are still smoking. 0 Try again to get each patient who smokes to set a quit date, accept referral to a group program, or use self-help materials. 0 Schedule support visits to reinforce a patient's decision to quit, deal with withdrawal, and discuss other relevant conoems. Such visits are especially important during the first 4 to 8 weeks of a quitting program. 0 Follow up by calling the patient or by setting a time for the patient to call you. When a patient feels that you care about his or her progress, it improves the chances that he or she will quit successfully. The Palhophysiologic Heels of Cigarette Smoke onlhePulmonarySyslem Effects on Airways A. Large Airways—modest increase in tracheobronchial glands associated with an increase in mucous secretion and increases in goblet cell number which leads to increased cough and sputum production in smokers. B. Small Airways (conducting air— ways 2 or 3 mm or less in diam— eter)—initial response is inflam- mation with associated ulceration and squamous metaplasia. Fibro— sis, increased muscle mass, narrowing of the airways, and an increase in goblet cells follow. C. Effects on Mucociliary Clearance ' Cigarette smoke produces structural and functional abnormalities in the airway mucociliary system. 0 Short-term exposure to ciga- rette smoke causes cilostasis in vitro, but has inconsistent effects on mucociliary function in man. Long—term exposure to cigarette smoke consistently causes an impairment of mucociliary clearance. This impairment is associated with epithelial lesions, mucous hypersecretion, and ciliary dysfunction. 0 Chronic bronchitis in smokers and ex—smokers is charac— terized by an impairment of mucociliary clearance. 0 Both the particulate phase and the gas phase of cigarette smoke are ciliotoxic. D. Effects on Lung Parenchyma 0 Increased numbers of inflam— matory cells are found in the lungs of cigarette smokers. These cells include macro- phages and, probably, neutro— phils, both of which can release elastase in the lung. Human neutrophil elastase produces emphysema when instilled into animal lungs. Alphal-antiprotease inhibits the action of elastase, and a very small number of people with a homozygeous deficien- cy of alphal-antiprotease are at increase risk of developing emphysema. The alphal-antiprotease activ- ity has been shown by lung lavage to be reduced in the bronchoalveolar fluids ob- tained from cigarette smokers and from rats exposed to cigarette smoke. The protease—antiprotease hypothesis suggests that em- physema results when there is excess elastase lytic activity as the result of increased concen- trations of inflammatory cells in the lung and of decreased levels of alphal-antiprotease secondary to oxidation by cigarette smoke. Smoking and Pulmonary Disease Risks of Smoking Smoking is associated with: 0 80 to 90 percent of chronic obstructive pulmonary disease (COPD) morbidity and mortality 0 Higher prevalence of cough and phlegm production. 0 Increased incidence and severity of asthma episodes and recurrent respiratory infections. 0 Decreased lung function. Differ— ences between smokers and non- smokers in measures of expiratory airflow are demonstrable by young adulthood and increase with num- ber of cigarettes smoked. 0 Increased prevalence of respira— tory tract infections in infants whose parents smoke. COPD Mortality 450 . . , 400 200 it. Rate per 100,000 100 45-54 35-44 55-64 Age Group 65-74 75-84 Death rate for bronchitis, emphysema, or both, per 100,000 population, by age and smoking status Source: Adopted from Rogot, E., Murray, I.L.: "Smoking and causes of death among US. veterans: 16 years of observation." Public Health Reports 95(3):213-222, May—June 1980. 10 Smoking and Pulmonary Disease Benefits of Quitting that of the never smoker even after 0 Cessation of smoking leads to a 20 years Of cessation. . _ decreased risk of mortality from ° Improved phy51cal functioning, chronic obstructive pulmonary reduced coughing and phlegm disease compared with that of production. continuing smokers. The residual 0 Greatly reduced risk of develop— excess risk of death for the eX- ing ventilatory limitation for smoker is directly proportional to smokers who quit before lung the overall lifetime exposure to function becomes abnormal. cigarette smoke and to the total number of years since one quits smoking. However, the risk of chronic obstructive pulmonary disease mortality among former smokers does not decline to equal — 00?!) Risk and Smoking Cessation 100 — Never smoked or not susceptible to smoke A '75— Smoked Stopped at 45 regularly and susceptible to F EVi (percent of value at age 25 50 _ its effects Disability 25 .1 Stopped at 65 Death 0 I I I I l I I I I l 25 50 75 Age (years) Risks for men with varying susceptibility to cigarette smoke and consequences of smoking cessation Source: Fletcher, C.M., Peto, R: "The natural history of chronic airflow obstruction.” British Medical Journal 1(6077):164571648, lune 25, 1977. ll The Pathophysiologic Effects of Cigarette Smoke on the Cardiovascular System A. Sympathomimetic Effects of Nicotine 0 Acute cardiovascular respon- ses with each cigarette smoked: 1 systolic blood pressure 1 diastolic blood pressure 1 heart rate 1 cardiac output 1 coronary blood flow 0 Vasoconstriction of peripheral arteries B. Effects Favoring Thrombosis 1 platelet aggregation 1 platelet adhesiveness l platelet survival 1 plasma fibrinogen l clotting time 1 blood viscosity 0 1 hematocrit C. Effects on Electrical Stability of the Myocardium 0 Nicotine may lower ventricular fibrillation threshold D. Effects on Oxygen Transport/ Utilization 0 Carbon monoxide from ciga— rette smoke binds to hemopro- teins—hemoglobin, myoglo— bin, cytochrome oxidase. 0 Smokers have levels of carbo- xyhemoglobin from 2 to 15 times higher than nonsmokers. 0 The amount of hemoglobin available for oxygen transport is reduced. The shift of the oxygen—hemoglobin curve to the left affects oxygen release to body tissues. E. Effects Favoring Atherogenesis 0 1 High density lipoprotein cholesterol 1 Low density lipoprotein cholesterol 1 Total serum cholesterol 1 Plasma free fatty acids Carbon monoxide may produce intimal hypoxia and increase endothelial permea- bility in the arterial wall. Repeated insults may favor lipid deposition. Smoking and Cardiovascular Disease Risks of Smoking Smoking is associated with: 0 30 percent of chronic heart disease deaths. 0 21 percent of deaths from other cardiovascular disease. 0 Increased risk of sudden death. 0 Increased perioperative mortality in coronary artery bypass patients. 0 Increased risk of death from atherosclerotic abdominal aneurysm. 0 Atherosclerotic peripheral vascular disease, increasing the risk of gangrene and limb amputation in these patients. 0 Graft occlusion in lower extremity reconstructive arterial surgery patients. 0 A synergistic interaction with hypertension and high blood cholesterol to greatly increase coronary heart disease risk. 0 Increased risk of cerebrovascular disease. 0 Increased risk of developing coronary heart disease and subarachnoid hemorrhage in women using oral contraceptives. _ Major Risk l'actor Combinations, 10-year Incidence of first Maior Coronary Events, in Men Age 30-59 210 180 150 120 j j 90 Rate per 1,000 No H CS only Risk Factors CS & C All 3 or Risk CS SI HBP Factors Risk Factor Status Definitions of the three major risk factors and their symbols: hypercholesterolemia (C), 2250 mg/dl; elevated blood pressure (HBP), diastolic pressure 290 mm Hg; cigarette smoking (CS), any current use of cigarettes at entry in Pooling Project Research Group. NOT E: All rates were age adjusted by 10—year age groups to the US. white male population, 1980. SOURCE: The Pooling Project Research Group as cited in Smoking and Health: A Report of the Surgeon General. DHHS, 1979. 13 Smoking and Cardiovascular Disease Benefits of Quitting 0 Cessation of smoking results in a substantial reduction in CHD death rates compared with those of per- sons who continue to smoke. Mor~ tality from CHD declines rapidly after cessation. Approximately 10 years following cessation the CHD death rate for those ex—smokers who consumed less than a pack of cigarettes daily is virtually identical to that of lifelong nonsmokers. For ex—smokers who had smoked more than one pack per day, the resid— ual risk of CHD mortality is pro— portional to the total lifetime exposure to cigarette smoke. 0 Smoking cessation plays an important role in the medical and/or surgical management of patients with cardiovascular disease leading to: —Decreased mortality after coronary bypass surgery. —Reduced morbidity and mortality in peripheral vascular disease. —Decreased mortality for post-Ml patients. —lncreased exercise tolerance on ECG. Cessation oi Smoking and Coronary Heart Disease Mortality Ratios oi Current Smokers Versus Ext-smokers 3 CHD Mortality Ratios Nronsmokes 1-9 10-20 21—39 40 and over Number of Cigarettes Smoked Daily Source: Rogot, E., Murray, l.L.: Smoking and causes of death among US veterans: 16 years of observation. Public Health Reports 95(3):213-222, May - June 1980. l4 — Smoking and Other Clinical Situations 0 A pregnant woman who smokes has an increased risk of miscar- riage, stillbirth, and of having a low birth weight infant. 0 Smoking during pregnancy may result in retarded physical and mental development of the child. 0 Smoking cessation can greatly improve pregnancy outcome. 0 Smokers have more peptic ulcers and, when they have an ulcer, are more likely to die from it. Peptic ulcers in smokers also respond poorly to treatment. 0 Smoking cessation improves ulcer treatment outcome. 0 Smoking increases the risk of developing cancer of multiple organ sites: Oral cavity Larynx Esophagus Lung Kidney Bladder Pancreas 0 Smoking cessation decreases cancer risk of multiple organ site‘s. SURGEON GENERAL’S WARNING: Smoking By Pregnant Women May Result In Fetal Injury, Premature Birth, And Low Birth Weight. 15 — mmmylnhflmwflhnmg'flnnpy Research shows that in many instances smoking can interfere with drug therapy. This chart lists commonly prescribed drugs and the effects a patient’s smoking can have on the drug’s efficacy. Drug The Effect Smoking has on Drug Therapy Acetaminophen The efficacy of this drug is not markedly affected by smoking. However, since plasma levels are lower in smokers, some patients may require higher doses than others. Antidepressants Higher-than—normal doses may be needed (Tricyclic) since plasma levels are lower in smokers. . Benzodiazepines These drugs are more rapidly eliminated by smokers, so that sedation is reduced. The effect is proportional to the amount of smok- ing— heavy smokers may need higher doses. Caffeine Smoking enhances caffeine elimination. Smokers generally experience less CNS I stimulation from caffeine than do nonsmokers. Cyanocobalamin Smoking lowers 812 levels. This can be (Vitamin B12) particularly important in dealing with malnourished patients. Glutethirnide Smoking appears to either lessen the volume (Doriden, etc) of distribution or increase the fraction of drug absorbed, thus enhancing CNS depression. Lidocaine HCl An increase of about 20 percent in serum (Xylocaine HCl, etc.) protein binding has been observed in smokers—the clinical significance is unclear. Oral contraceptives The risk of thromboembolic events for those who use oral contraceptives increases with more than 15 cigarettes a day, especially after age 35. Pentazocine HCl Smoking greatly enhances metabolism. Increased maintenance doses may be needed if the initial dose is not affected. Phenothiazines Decreased effect of the drugs has been reported for smokers. Phenylbutazone Smoking nearly doubles metabolic clearance. (Azolid, Butazolidin, etc) Higher doses may be needed by smokers. Propoxyphene HCl Decreased efficacy is reported in smokers—— (Darvon, SK-65, etc.) this may be due to enhanced metabolism. Propranolol HCl Reports of increased clearance and reduced (Inderal) therapeutic effect in smokers continue to appear. Propranolol and smoking both impair peripheral circulation, and smoking may negate the beneficial effects of propranolol in ischemic heart disease. Theophylline Half-life is decreased in smokers because of accelerated metabolism. Source: Lipman, A.G.: "How smoking interferes with drug therapy." Modern Medicine, pp. 141-142, August 1985. l6 Row to Recognlze Tobacco Dependence Individuals who are considered dependent on tobacco have these characteristics: 0 They have used tobacco continually for at least 1 month, and at least one of the following: 0 They have made serious attempts to stop or significantly reduce the amount of tobacco used on a permanent basis but they have been unsuccessful. 0 Their attempts to stop smoking have led to the development of physical withdrawal symptoms. 0 They continue to use tobacco despite a serious physical disorder (e.g., a respiratory or cardiovascular disease) that they know is exacerbated by tobacco use. Source: American Psychiatric Association Diagnostic and Statistical Manual, 3rd edition, Washington, DC, APA Press, 1981. Commend. Relapse Environmental/ Social 0 Social celebrations 0 Alcohol consumption 0 Habitual smoking cues 0 Social pressure from peers Psychological 0 Negative emotional state 0 Stressful events 0 Inadequate motivation to quit Physiological 0 Craving for cigarettes 0 Withdrawal symptoms 0 Weight gain Thellcollnel'lfiulnwelflyndm Within 24 hours of abrupt smoking cessation or significant reduction in tobacco use, any of these symp- toms may occur: 0 Craving for tobacco 0 Irritability 0 Anxiety 0 Difficulty concentrating 0 Restlessness 0 Headache 0 Drowsiness ° Gastrointestinal disturbance Patients need to know that: 0 Physical withdrawal symptoms are possible. 0 These symptoms are temporary, usually lasting 1 or 2 weeks. 0 You will support them through this difficult period. 0 Ex—smokers may still want a cigarette after physical withdrawal is over, but this craving will be psychological, not physical. 0 Nicotine chewing gum may reduce withdrawal symptoms, particularly in heavily dependent smokers. However, psychological and social factors are also important and must be addressed. Source: American Psychiatric Association Diagnostic and Statistical Manual, 3rd edition, Washington, DC, APA Press, 1981. Seven Steps to Prevent Relapse l. Remind patients at each office visit of the clinical consequences of smoking. 2. Provide positive reinforcement, em- phasizing the benefits of quitting. -3. Provide take-home materials that encourage maintenance of cessation. 4. Refer patients to community main— tenance programs or ex—smokers’ hot- lines. 5. Emphasize that repeated cessation attempts are often necessary for success. 6. Prepare patients for the short-term results of cessation—both possible withdrawal symptoms and immediate benefits (e.g., better breath, better ability to taste). 7. Follow up with patients between office visits by telephone or mail. 19 Patient Smoking Profile Please answer the following questions: A. l. 10. ll. 12. 14. 15. How soon after you wake up do you smoke your first cigarette? a. after thirty minutes b. within thirty minutes Do you find it difficult to refrain from smoking in places where it is forbidden, such as the library, theater, or doctor's office? a. yes b. no Which of all the cigarettes you smoke in a day is the most satisfying one? a. any other than the first one in the morning b. the first one in the morning How many cigarettes a day do you smoke? a. l—15 b. 16-25 c. 26 or more . Do you smoke more during the morning than during the rest of the day? a. yes b. no Do you smoke when you are so ill that you are in bed most of the day? a. yes b. no Does the brand you smoke have a low, medium, or high nicotine content? (Refer to your cigarette pack.) a. low (0.9 mg. or less) b. medium (1.0-1.2 mg.) c. high (1.3 mg. or more) How often do you inhale the smoke from your cigarette? a. never b. sometimes c. always . Do you want to stop smoking? a. yes b. no Have you stopped smoking or tried to stop in the past? a. yes b. no Have you participated in organized smoking cessation programs or used self-help materials? a. yes b. no Do you think you can successfully stop smoking? a. yes b. no . Do you believe that you will gain weight if you stop smoking? a. yes b. no Do you have any other concerns about quitting? What method of quitting do you think would work best for you? 21 Interpreting Patient Responses A. The questions in block A relate to nicotine dependence and level of smoking. The questions are scored so that higher points are always given for answers indicating a higher level of addiction to cigarettes.* Question 1: 1 point is assigned to smoking within 30 minutes. Questions 2, Items are scored with one point for yes answers. 5, and 6: Question 3: One point is assigned for answering the ”first cigarette in the morning." Question 4: Smokers are categorized as light (score of 0, 1-15 cigarettes), moderate (score of 1, 16—25 cigarettes), and heavy (score of 2, 26 or more cigarettes). Question 7: The brands are classified into three categories with low (score of 0), medium (score of l), and high (score of 2) nicotine levels. Question 8: Frequency of inhalation is divided into three categories: never (score of 0), often (score of l), and always (score of 2). Scoring: A score of 6 or greater indicates a high probability that the smoker is tolerant to nicotine and that quitting smoking may be accompanied by some physiologic discomfort. B. The questions in block B assist in the determination of the patient’s previous smoking cessation attempts as well as commitment to and beliefs about ability to succeed in trying again. C. The questions in block C identify each patient’s perceived barriers to quitting and the method the patient thinks he or she might use. Responses can serve as a cue for your discussion. *Source: Fagerstrom, K.Q.: Measuring degree of physical dependence to tobacco with reference to individualization of treatment. Addictive Behavior 3:235—241, 1978, Pergamon Press, Ltd. Fagerstrom, K.Q., Melin, B.: Nicotine chewing gum in smoking cessation: efficiency, nicotine dependence, therapy duration, and clinical recommendations. 1n: Krasnegor, NA. (ed) Behavioral Analysis and Treatment of Substance Abuse. National Institute on Drug Abuse Research Monograph No. 25. NTIS PB #80—112428, Washington, DC, 1979. Fagerstrom, K.O.: "Tolerance, withdrawal and dependence on tobacco and smoking termination." lntemational Review of Applied Psychology 32(1):29~52, 1983. larvik, M.E., Schneider, N.G.: "Degree of addiction and effectiveness of nicotine gum therapy for smoking." American loumal of Psychiatry 141(6):790-791, 1984. 22 Personal Advice About Smoking Patient Characteristics Implications Possible Interventions Light smoker or high self-efficacy «.~._._:.._.<_W .. ~63. . c - A .— Light smokers, who are less dependent on nicotine, may have fewer physical withdrawal symptoms. Patients who believe they can quit on their own have a better chance of success. Suggest community self-help program or self—help materials. or Suggest going "cold turkey,” per- haps with the help of supportive materials such as ALA FREEDOM FROM SMOKING® manuals. (See p. 30 for description.) Ask patient about progress at next visit. Nicotine—dependent or low self—efficacy Some patients may need more intensive support to quit. Physical withdrawal symptoms will stop within 1 to 3 weeks. A relapse is not a failure; most smokers need more than one quit attempt to succeed. Most relapses occur in the first 3 months after quitting. Smoker sets a quit date; schedule a followup visit within 4-8 weeks (period of greatest likelihood of relapse). 01' Refer patient to community smoking cessation program. Reinforce stop-smoking message by contacting patient during first month with encouragement. and/or Consider prescribing nicotine chewing gum.* *Note: It should be emphasized that this product is best used as an adjunct to a physician-supervised, community- based, or self-help behavior change program that provides necessary support for coping with psychological and social dependency factors. Concerned about barriers to quitting, e.g., weight gain Some ex—smokers do gain weight, but benefits to health are far greater than the drawbacks of a small weight gain, which can probably be lost over time. A small increase in weight may not hurt appearance; smoking itself is unattractive, causing bad breath, yellow teeth, stale clothing odor, and, possibly, wrinkled skin. Avoid sweet-tasting high calorie foods; there is some evidence that nicotine withdrawal may lead to a craving for sweets. Provide weight control information. Contact your local American Lung Association for a copy of their pamphlet entitled "Stop Smoking Stay Trim." Review the patient's reasons for quitting. Ol’ Refer patient to a nutritionist for refractory weight gain or if other nutrition—related CVD risk factors are present. Reinforce progress or provide support at next visit. 23 Personal Advice About Smoking (continued) Patient Characteristics Implications Possible Interventions Adolescents 0 Generally experiment between ages ll and 15. 0 Reluctant to admit smoking when asked. 0 Time perspective is short—term. 0 Smoke primarily for social reasons: to win peer approval, show independence or rebellion, look grown-up or sophisticated. 0 Probe for information about smoking in a nonthreatening way. 0 Avoid a disease—oriented approach that focuses on long-term consequences. 0 Focus on immediate effects such as unpleasant breath, discolored teeth, and stained fingers. 0 Discuss the acute effects of nicotine and carbon monoxide on the cardiovascular system. Relate to possible effect on performance in sports and other physical activities. 0 Point out the fact that most adults or teens don't smoke and that patient shouldn't be deceived by cigarette advertising featuring young, active, and apparently successful young men and women as smokers. Young Adults (twenties and thirties) 0 Majority express a desire to quit but find that they are tobacco dependent. 0 Many young adults are able to quit on their own. 0 High rate of smoking among women in this age group compared to men. 0 A significant number of women who smoke may also be taking oral contraceptives and are at even greater risk of cardiovascular disease. 0 Highest pregnancy rates occur in this group. Cigarette smoking by pregnant women leads to a number of adverse consequences for the unborn child. 0 Parents who smoke expose their children to the potentially harmful effects of passive smoking (involun— tary exposure of nonsmokers). Respiratory infections are more frequent in infants whose parents smoke. 0 Make patient aware of the acute effects of smoking and explain that quitting now gives the body a chance to repair itself. Probe for signs of minor lung dysfunction and morning cough. Stress that tobacco smoke components com— promise the cleaning mechanisms of the lungs. 0 Use pulmonary function test results as an opportunity to discuss the effects of smoking and the benefits of quitting before irre- versible changes take place. 0 In prescribing oral contracep- tives to a smoker, discuss the excess risk of cardiovascular disease. If patient feels that oral contraceptives are her only option, urge her to consider giving up cigarettes. 0 With expectant mothers and parents of young children, discuss the effects of passive smoking. Encourage cessation in order to benefit family health. 24 2‘ O“. .. h“, L W iv #! 5 a Personal Advice About Smoking (continued) Patient Characteristics Implications Possible Interventions Older Asymptomatic Adults (forties and fifties) 0 Many have attempted to quit but have failed. 0 Many have specific concerns or needs that keep them from quitting (anxiety, weight gain, etc.) ' Most of these smokers respond well to office counseling and may be motivated to try to quit. 0 Emphasize that smoking often leads to lingering disability rather than death. Stress the importance of cessation to improve the patient’s chances of enjoying the later years of his or her life. 0 Those smokers who have tried to quit unsuccessfully may need to be referred to a community-based smoking cessation program. A referral list should be developed so that you can select the best option. 0 Schedule support visits to deal with withdrawal concerns and to solidify the initial transition to becoming a nonsmoker. These appointments should be set for the most critical time—the 4—8 weeks after initial cessation. 0 Stress the fact that multiple quit attempts are often needed, and that the patient’s apparently unsuccessful attempts in the past may have better positioned him or her to succeed now. Older Symptomatic Smokers (forties and fifties) 0 May be frustrating to work with, since they continue to smoke despite the presence of smoking- related problems. 0 Often feel that damage is already done and adopt fatalistic attitude. 0 Referral to an outside program may be the most effective option. However, smoking cessation should be stressed as an important com- ponent in the treatment of the patient's disease. The benefits of smoking cessation in preventing exacerbations or in stabilizing his or her condition should be stressed. 0 Continuing support and encour- agement are very important. Be sympathetic to the logic of these smokers even if their behavior appears to be irrational. Assist them in reappraising their priorities and immediate goals. Source: Pechacek, T.F., Grimm, RH; Cigarette Smoking and the Prevention of Coronary Heart Disease. In: Podell, R.N., Steward, M.M. (eds) Primary Prevention of Coronary Heart Disease: A Practical Guide {or the Clinician. Reading, Massachusetts, Addison-Wesley Publishing Company, 1983. 25 WMWPafimnafionaflnm Rationalization I am under a lot of stress, and smoking relaxes me. Smoking stimulates me and helps me to be more effective in my work. I have already cut down to a safe level. I only smoke safe, low-tar/low— nicotine cigarettes. I don't have the willpower to give up smoking. Physician Response Your body has become accustomed to nicotine, so you naturally feel more relaxed when you get the nicotine you have come to depend on. But nicotine is actually a stimulant that temporarily raises heart rate, blood pressure, and adrenaline level. After a few weeks of not smoking, most ex—smokers feel less nervous. Difficulty in concentrating can be a symptom of nicotine withdrawal, but it is a short—term effect. Over time, the body and brain function more efficiently when you don't smoke, because carbon monoxide from cigarettes is displaced by oxygen in the bloodstream. Cutting down is a good first step toward quitting. But smoking at any level increases the risk of illness. And some smokers who cut back inhale more often and more deeply, thus maintaining nicotine dependence. It is best to quit smoking completely. Low-tar cigarettes still contain harmful substances. Many smokers inhale more often or more deeply and thus maintain their nicotine levels. Carbon monoxide intake often increases with a switch to low-tar cigarettes. It can be hard for some people to give up smoking, but for others it is much easier than they expect. More than 3 million Americans quit every year. It may take more than one attempt for you to succeed, and you may need to try different methods of quitting. I will give you all the support I can. 26 Medical Practice Protocol Overview for Smoking Intervention Waiting Room 0 Promote a nonsmoking environment. 0 Display ”No Smoking" signs. 0 Adopt a nonsmoking policy for office staff. Create opportunities for your patient to ask for assistance in smoking cessation: 0 Have copies of PATIENT SMOKING PROFILE prominently available. 0 Include pamphlets about smoking cessation in waiting room materials. 0 Use video education trigger films such as We Can’t Go On Like This. Patient History Incorporate smoking questions such as: 0 Number of cigarettes smoked daily 0 Number of years as smoker ' Depth of inhalation 0 Past efforts at quitting, including length of time off cigarettes, problems encountered, reasons for relapse Solicit smoking-related symptoms, such as: 0 Cough 0 Sputum production 0 Shortness of breath 0 Recurrent respiratory infections Review family history of tobacco-related diseases such as: 0 Coronary heart disease 0 Chronic obstructive pulmonary disease ' Cancer Physical Examination Make the physical examination an intervention: 0 Highlight examination of the cardiovascular system and lungs. 0 Stress relationship of smoking to these systems. 0 Relate relevant findings such as hoarse cough and diminished breath sounds to smoking, assuming there is no other cause. 0 Inform patient of the acute effects of smoking on heart rate, blood pressure, blood vessel constriction, as well as inactivation of bronchial cilia and oxygen deprivation due to carbon monoxide. 0 Discuss the short- and long-term benefits of stopping smoking for the heart and lungs. Office and Laboratory Tests Use medical test results to personalize the anti—smoking message. For example: 0 Spirometric values —Normal Stress the benefits of quitting now before damage is done. —Abnorrnal Stress that it is critical for patient to stop smoking to help limit further decline in lung function. 0 Blood cholesterol determinations, blood pressure measurements —When elevated Stress the greatly increased risk of heart disease when two or more major risk factors are present. 27 Medical Practlce Protocol Overview for Smoking Inlemntlon (conflnued) Diagnosis/ Treatment Plan Incorporate smoking cessation into the treatment plan: 0 When a patient is diagnosed as having a tobacco-related disease or a disease exacerbated by smoking, stress importance of smoking cessation in treating the disease. 0 When prescribing a drug that may interact with smoking, inform patient of such interactions. 0 Take advantage of followup visits to further reinforce the anti-smoking message and to check on patient progress in smoking cessation. 28 Smoking Gwalior: Resources Local Resources for Smoking Cessation Programs Name of Organization Address Phone Number American Lung Association American Cancer Society American Heart Association Local Health Department Hospitals Private Proprietary Programs Community College Programs — Smoking We'd like to help you help others quit! Everyone knows that smoking is harmful. Still, many people smoke and can't imagine giving it up. The staff of the National Heart, Lung, and Blood Institute knows how hard it can be to help smokers quit. So we are making available on videotape a series of persuasive short films that can help trigger discussions with your patients who smoke. The title of the film series is We Can’t Go On Like This. It was developed and first used during the Multiple Risk Factor Intervention Trial (MRF IT), a 7—year clinical study of the effects of a variety of interventions on cardiovascular disease incidence. Smoking cessation groups in the study achieved a 50 percent quit rate, attributable in part to use of the films. The seven video vignettes, each of which runs for 3 to 7 minutes, are on a 32-minute video. The films are witty, soft—sell, and sympathetic; they feature scenes that illustrate the psychology of smoking, the subtle and sometimes not—so—subtle models that lure people to smoke, and the pain of trying to stop. Contact: National Audio Visual Center Order Section IQ, Dept. T—F Washington, DC 20409 A Physician Talks About Smoking: A Slide Presentation "A Physician Talks About Smoking" is a new slide film series designed to meet the needs of physicians and other health care professionals who are called upon to speak to medical and lay audiences on smoking and health. The slides summarize: ' Cigarette Smoking as a Risk Factor for Premature Morbidity/Mortality How Cigarettes Cause Disease Costs of Smoking—Related Disease and Death Who Smokes, How Much, and Why Suggested commentary is provided for each slide. However, speakers are encouraged to present the material in their own way, including deleting and reordering the sequence of slides or adding slides of their own to supplement the presentation to better meet the needs of their audience. For further information contact: Office on Smoking and Health Public Health Service Rockville, MD 20857 (301) 443—1690 — About the ALA's "Freedom From Smoking"® Programs The American Lung Association , in collaboration with its medical section, the American Thoracic Society, has developed and evaluated two self-help smoking cessation programs. FREEDOM FROM SMOKING® in 20 Days emphasizes the benefits of a nonsmoking lifestyle and recommends a day—by—day technique to quit smok— ing. The manual encourages the smoker to keep a record of the num— ber of cigarettes that he or she smokes, identify smoking triggers, and sign contracts to quit. Also included are weight control information, deep breathing and muscle relaxation exer— cises, and ways to prepare for situa— tions that will trigger the desire to smoke again. The maintenance manual, A LIFE— TIME OF FREEDOM FROM SMOK— ING'r® , is designed to be used by ex— smokers to maintain their nonsmoking behavior. This publication emphasizes techniques for coping with situations that trigger the urge to smoke and provides an upbeat plan of action to stay off cigarettes permanently. An intensive evaluation of the manuals found a 19 percent quit rate (reported abstinence within the 30 day period prior to the 12—month follow- up contact). Nonsmoking prevalence increased over time. This suggests that many smokers eventually succeeded in quitting after one or more attempts. Self-help materials encourage re— newed efforts and can be used as resources for subsequent cessation. The American Lung Association also has developed a seven session FREEDOM FROM SMOKING® quit— smoking clinic that provides a group setting for smokers who want to be— come nonsmokers. The nonsmoking prevalence rate for clinics is 29.3 percent. IN CONTROL: A Home Video FREEDOM FROM SMOKING/3) PROGRAM is also available for patients to quit smoking at home. There is a guide for health care facilities which enables physicians to present the video in their offices. For further information contact: Your local American Lung Association office. Reference Davis, A.L., et at: “Settihelp smoking cessation and maintenance programs: A comparative study with llmonth follow-up by the American Lung Association." American Journal ofPuinc Health, 74(11):1212712l7, November 1984. 3O — Bibliography 1. American Heart Association. Cigarette Smoking and Cardiovascular Diseases: A Statement for Health Professionals Prepared by a Task Force Appointed by the Steering Committee. Dallas, 1985. 2. American Psychiatric Association. Diagnostic and Statistical Manual, 3rd edition, Washington, DC, APA Press, 1981. 3. American Thoracic Society. American Thoracic Society Official Statement on Cigarette Smoking and Health. New York, November 1984. 4. Brownell, K., Marlatt, G., et al.: "Understanding and preventing relapse.” American Psychologist, in press. 5. Burt, A., Illingworth, D., Shaw, PR.D., et al.: "Stopping smoking after myocardial infarction.” Lancet 1:304—306, 1974. 6. Davis, A.L., et al.: ”Self-help smoking cessation and maintenance programs: A comparative study with 12-month follow—up by the American Lung Association." American Journal of Public Health 74(11):1212-l2l7, November 1984. 7. Fagerstrom, K.O.: “Measuring degree of physical dependence to tobacco with reference to individualization of treatment." Addictive Behavior 3:235241, 1978. 8. Fagerstrom, KO; ”Tolerance, withdrawal and dependence on tobacco and smoking termination.” International Review of Applied Psychology 32(1):29-52, January 1983. 9. Fagerstrom, K0,, Melin, B.: "Nicotine chewing gum in smoking cessation: efficiency, nicotine dependence, therapy duration, and Clinical recommendations." In: Krasnegor, N.A. (ed) Behavioral Analysis and Treatment of Substance Abuse. National Institute on Drug Abuse Research Monograph No. 25. NTIS PB #80112428, Washington, DC, 1979. 10. Fletcher, C.M., Peto, R.: ”The natural history of chronic airflow obstruction.” British Medical Journal 1(6077):1645—1648, lune 25, 1977. 11. Grunberg, N., Bowen, D.: "Coping with the sequel of smoking cessation.” Journal of Cardiac Rehabilitation 5:285-289, lune 1985. 12. Jarvik, M.E., Schneider, N.G.: "Degree of addiction and effectiveness of nicotine gum therapy for smoking." American Journal of Psychiatry 141(6):790-791, June 1984. 13. Kannel, W., et al.: ”Optimal resources for primary prevention of atherosclerotic diseases.” Circulation 157A—205A, July 1984. 14. Lichtenstein, E., Danaher, B.G.: ”What can the physician do to assist the patient to stop smoking?” COLD: Clinical Treatment and Management, St. Louis, Mosby, 1978. 15. Lipman, A.G.: “How smoking interferes with drug therapy." Modern Medicine, pp. 141-142, August 1985. 16. Marlatt, G.A., Gordon, I.R.: ”Deters minants of relapse: Implications for the maintenance of behavior change.” In: Davidson, PO, Davidson, S.M. (eds) Behavioral Medicine: Changing Health Lifestyles, New York, Brunner/Mazel, 1980. 17. Department of Health, Education, and Welfare, US. Public Health Service, Centers for Disease Control and National Clearinghouse on Smoking and Health. Adult Use of Tobacco 1975, lune 1976. 18. Pacific Mutual Life Insurance Company, Newport Beach, California. Health Maintenance Survey, conducted by Louis Harris and Associates, Inc, November, 1978. 19. Pechacek, T.F., Grimm, R.H.: Cigarette smoking and the prevention of coronary heart disease. In: Podell, R.N., Steward, M.M. (eds) Primary Prevention of Coronary Heart Disease: A Practical Guide for the Clinician. Reading, Massachusetts, AddisonAWesley Publishing Company, 1983. 20. Prochaska, 1., et al.: "Predicting change in smoking status for self- changers.” Addictive Behavior, 10:395406, 1985. 21. Rogot, 13., Murray, I.L.: ”Smoking and causes of death among US. veterans: 16 years of observation." Public Health Reports 95(3):213-222. May-June 1980. 22. Rose, G., Hamilton, PIS: ”A ran- domized controlled trial of the effect on middle—aged men of advice to stop smoke ing." Journal of Epidemiology and Community Health 32(4):275-281, 1978. 23. Russell, M.A.H., Wilson C., Taylor, C., Baker, D.C.: Effect of general practitioners advice against smoking. British Medical Journal 22231235, 1979. 24. Smoking and Health. A Report of the Surgeon General. DHEW (PHS) 79750066, 1979. 25. The Health Consequences of Smoking: Cardiovascular Disease. A Report of the Surgeon General. DHHS, (PHS) 84750204 1983. 26. The Health Consequences of Smoking: Chronic Obstructive Lung Disease, A Report of the Surgeon General. DHHS, (PHS) 84-50205, 1984. 31 — DISCRIMINATION PROHIBITED: Under provisions of applicable public laws enacted by Congress since 1964, no person in the United States shall, on the grounds of race, color, national origin, handicap, or age, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity (or, on the basis of sex, with respect to any education program or activity) receiving Federal financial assistance. In addition, Executive Order 11141 prohibits discrimination on the basis of age by contractors and subcontractors in the performance of Federal contracts, and Executive Order 11246 states that no federally funded contractor may discriminate against any employee or applicant for employment because of race, color, religion, sex, or national origin. Therefore, the National Heart, Lung, and Blood Institute must be operated in compliance with these laws and Executive Orders. NIH Publication No. 862178 August 1986 W