The Intersection of Tobacco and Heart Disease: State and Territorial Opportunities for World No Tobacco Day

May 30, 2018|1:16 p.m.| Marcus Plescia, MD, MPH | ASTHO Chief Medical Officer Forum

Each year, the World Health Organization (WHO) and partners recognize World No Tobacco Day on May 31 to raise awareness about the risks associated with tobacco use. On this day, partners are encouraged to advocate for effective policies to reduce tobacco consumption and promote focused campaigns. This year, World No Tobacco Day focuses on tobacco and heart disease, two public health issues on which ASTHO has focused and provided ongoing support to state and territorial public health departments.

Great progress has been made to reduce tobacco use and resulting tobacco-related illnesses in the United States. State public health departments have led this work through efforts to ban smoking in public places and restrict youth access by price increases and social messaging. However, the rising use of e-cigarettes is a growing concern, addressed in a previous column. In addition, significant health disparities in current tobacco use must still be addressed. Tobacco use is significantly higher among individuals suffering from behavioral health problems and the burden of associated chronic diseases, such as heart disease, cancer, and emphysema, is far greater than in the general population. Heightened concern about addiction stemming from the opioid epidemic creates an opportunity to advocate for and provide wholistic interventions to improve the health of this population. Public health leaders can challenge longstanding practices of condoning and even encouraging tobacco use by educating the behavioral health community about high rates of tobacco-related illnesses among individuals with behavioral health conditions. They can advocate for comprehensive smoke-free policies in these institutional settings and support the aggressive use of cessation support by expanding coverage for nicotine replacement therapy and enhanced access to quit lines and other supportive modalities.

Heart disease is the leading cause of death in the United States, with approximately 30 percent of all heart disease deaths attributed to smoking cigarettes. Evidence-based tobacco control strategies alone can significantly reduce the burden of suffering from health disease in the United States. However, supporting better control of high blood pressure, cholesterol, and diabetes are other highly effective approaches. There is significant room for improvement here, since only about half of individuals with known hypertension have their blood pressure under control, and many more do not even know that they have high blood pressure.

Over the past five years, ASTHO has been supported by the CDC Division of Heart Disease and Stroke Prevention to expand efforts to improve control of hypertension in 22 states and the territory of Palau.  These projects have focused on working with healthcare systems, practices and payors, and are closely aligned with the CDC 6|18 Initiative. Much of the work has focused on team-based care models, which are highly effective and strongly endorsed by the Community Preventive Services Task Force. However, supporting patient self-management of blood pressure is an emerging and particularly compelling role for public health, since 80 percent of care efforts occur outside traditional healthcare settings. Public health can work with pharmacists to make it easier for individuals to adhere to multidrug treatment regimens through systems change interventions such as increasing the use of single tablet medication combinations or adopting new medication packaging that helps simplify dosing. The same train-the-trainer modalities that have been used to support diabetes control in community agencies can be applied to hypertension through partnerships with community entities, such as churches and the YMCA.

Hypertension is more prevalent among African Americans and less likely to be medically controlled. The new Million Hearts 2022 priorities emphasize improving outcomes for African Americans with hypertension. Public health departments can expand community clinical linkages to improve hypertension control in special populations. Self-monitoring of blood pressure has emerged as a particularly compelling strategy. Patients with known or suspected hypertension are provided validated home blood pressure monitors to measure blood pressure regularly at home or in community environments. States can help support these efforts by working with specialty societies, federally qualified health centers, and other provider groups to encourage self-monitoring of blood pressure. They can work with payors to expand insurance coverage to help patients purchase monitors and reimburse for the clinical support services required for self-administered blood pressure monitoring. In states with well-established programs, community health workers can help train and support individuals to self-monitor blood pressure.

Effective public health work requires extensive support and collaboration. Every state health department has a tobacco control program, as well as heart disease and stroke prevention initiatives. These programs can observe World No Tobacco day by comparing their resources and assets, and identifying ways to share best practices and work together on interventions that will impact population health.