ABC: a lifesaving intervention for smokers

1. ABC: a lifesaving intervention for smokers Vicki Oldfield and Dorothy Clendon Ministry of Health

2. The risks of smoking are large About half of long term smokers die from a smoking-related disease On average they lose 15 years of life 25% of smokers die in middle age Around 5000 smoking-related deaths each year Biggest single cause of preventable deaths in NZ Biggest single cause of preventable deaths in NZ

3. The size of the problem Use of a sUse of a s

4. Cigarette consumption in New Zealand Up to 20% of the population have mental health illness, yet they smoke a third of all cigarettes. This means mental health patients are smoking heavily = more damageUp to 20% of the population have mental health illness, yet they smoke a third of all cigarettes. This means mental health patients are smoking heavily = more damage

5. Prevalence of smoking and depression Smoking is higher among patients with depression than among the general population. If you�re depressed you�re more likely to smoke, and if you smoke you�re more likely to suffer depression.Smoking is higher among patients with depression than among the general population. If you�re depressed you�re more likely to smoke, and if you smoke you�re more likely to suffer depression.

6. Smoking prevalence in nursing staff Smoking prevalence in nurses is less than 15%, but� Grace Wong�s ASKKAN survey showed that 29% of mental health nurses smoke, compared to less than 15% of other nurses.. Other rates are: - 3% among doctors 21-23% of general population Grace Wong�s ASKKAN survey showed that 29% of mental health nurses smoke, compared to less than 15% of other nurses.. Other rates are: - 3% among doctors 21-23% of general population

7. Impacts of Smoking � Health Effects Psychiatric patients who smoke have Higher incidence of illicit drug use Poorer treatment compliance Lower Global Assessment Functioning (GAF) score More hospitalisations Higher medication doses Key Point - Psychiatric patients who smoke also have a higher incidence of illicit drug use, poorer treatment compliance, and lower Global Assessment Functioning (GAF) scores than those who don�t smoke. This study aimed to compare demographic, clinical, treatment, and health plan characteristics of psychiatric patients who were smokers with those who don�t smoke. A questionnaire was administered to 615 psychiatrists, all members of the American Psychiatric Association who spent 15 hours or more in direct patient care. Psychiatrists provided data on 1843 of their patients. Data for patients for whom the smoking status was unknown were excluded from the analyses, leaving a total of 1752 patients. Of these patients, 16.6% had nicotine problems and 83.4% did not. The group of patients who smoked had a significantly higher number who were male, divorced or separated, disabled, and with fewer years of education. This group also had fewer patients under the age of 18. Among current smokers, 22.3% were currently using illicit drugs, compared with 2.9% of nonsmokers (P=.0000). Treatment compliance was poor among 39.0% of smokers and 16.3% of nonsmokers (P=.0000). Low GAF scores (50 or below) were seen in 52.3% of current smokers and 30.9% of nonsmokers (P=.000). Key Point - Psychiatric patients who smoke also have a higher incidence of illicit drug use, poorer treatment compliance, and lower Global Assessment Functioning (GAF) scores than those who don�t smoke. This study aimed to compare demographic, clinical, treatment, and health plan characteristics of psychiatric patients who were smokers with those who don�t smoke. A questionnaire was administered to 615 psychiatrists, all members of the American Psychiatric Association who spent 15 hours or more in direct patient care. Psychiatrists provided data on 1843 of their patients. Data for patients for whom the smoking status was unknown were excluded from the analyses, leaving a total of 1752 patients. Of these patients, 16.6% had nicotine problems and 83.4% did not. The group of patients who smoked had a significantly higher number who were male, divorced or separated, disabled, and with fewer years of education. This group also had fewer patients under the age of 18. Among current smokers, 22.3% were currently using illicit drugs, compared with 2.9% of nonsmokers (P=.0000). Treatment compliance was poor among 39.0% of smokers and 16.3% of nonsmokers (P=.0000). Low GAF scores (50 or below) were seen in 52.3% of current smokers and 30.9% of nonsmokers (P=.000).

8. Impacts of Smoking - Financial Implications Key Point � over � of the monthly budget of a schizophrenic patients is taken up by cigarettes The financial burdens in the schizophrenic population are exacerbated by daily smoking habits. As part of a larger study of patients with schizophrenia who smoke, 78 participants provided data on financial assistance, as well as tobacco use. Most of the patients (87.2%) received public assistance. Patients spent a median of $142.50 per month on cigarettes, a median percentage of 27.4% of their monthly income. This large percentage of income spent on cigarettes compromises aspects of quality of life such as adequate housing and nutrition, or occasional entertainment desires, which are already adversely affected in this population. Key Point � over � of the monthly budget of a schizophrenic patients is taken up by cigarettes The financial burdens in the schizophrenic population are exacerbated by daily smoking habits. As part of a larger study of patients with schizophrenia who smoke, 78 participants provided data on financial assistance, as well as tobacco use. Most of the patients (87.2%) received public assistance. Patients spent a median of $142.50 per month on cigarettes, a median percentage of 27.4% of their monthly income. This large percentage of income spent on cigarettes compromises aspects of quality of life such as adequate housing and nutrition, or occasional entertainment desires, which are already adversely affected in this population.

9. Stopping smoking works There are benefits from quitting at any age Smokers who quit before age 35-40 reduce their risk of dying early to that of a non-smoker over time Most smokers want to quit* 69% of smokers tried to quit in last 5 years 44% of smokers tried to quit at least once in the last year Maori, Pacific and young smokers and those with mental illness are just as likely to have tried to quit * NZ Tobacco Use Survey 2006 There is a gap between current and best practice

10. Why Increase Quit Attempts? This slide shows the % of smokers who quit if all smokers made one only quit attempt per year from the age of 35. The dark blue bars are that of the �cold turkey� approach. Note what can be achieved when medication (light blue bars) is added and when support and medication are combined In addition, we need to move this curve forward 15 years so that smokers have quit by age 35, thereby reducing over time their lifetime risk to that of non-smokers. This is what we need to be aiming for! This slide shows the % of smokers who quit if all smokers made one only quit attempt per year from the age of 35. The dark blue bars are that of the �cold turkey� approach. Note what can be achieved when medication (light blue bars) is added and when support and medication are combined In addition, we need to move this curve forward 15 years so that smokers have quit by age 35, thereby reducing over time their lifetime risk to that of non-smokers. This is what we need to be aiming for!

11. ABC � a simple reminder to provide brief advice routinely New Zealand Smoking Cessation Guidelines A Ask whether a person smokes B give Brief advice to quit to all people who smoke and C make an offer of Cessation treatment � provide and/or refer This replaces the 5 �A�s� The NZ smoking cessation guidelines use a simple memory aid to encourage all health professionals to intervene with smokers 5 �A�s � Ask, advise, assess, assist, arrange. ABC is much simpler, no need to assess motivation or readiness to quit. The NZ smoking cessation guidelines use a simple memory aid to encourage all health professionals to intervene with smokers 5 �A�s � Ask, advise, assess, assist, arrange. ABC is much simpler, no need to assess motivation or readiness to quit.

12. Brief Advice The key to increasing quit rates is to prompt more smokers to make more supported quit attempts more often Importantly brief advice by health professionals is proven to be effective NNT = 40 Brief advice is just that � brief! It is not a counseling session The purpose is to prompt a smoker to consider or make a quit attempt The evidence for brief advice to quit comes primarily from studies of doctors. There is however no reason to believe that advice given by other heal professionals would not also have an impact. The number needed to treat (NNT) is 40. That is for every 40 smokers briefly advised to quit smoking, 1 will quit smoking long-term who would otherwise not have managed to do so. The evidence for brief advice to quit comes primarily from studies of doctors. There is however no reason to believe that advice given by other heal professionals would not also have an impact. The number needed to treat (NNT) is 40. That is for every 40 smokers briefly advised to quit smoking, 1 will quit smoking long-term who would otherwise not have managed to do so.

13. Cessation Support - Effective treatments These are treatments on available in NZ An offer of at least one of these should be made to all smokers These are treatments on available in NZ An offer of at least one of these should be made to all smokers

14. Is Cessation Safe in the Mentally Ill? Anxiety disorders: No evidence of exacerbation of anxiety disorders. Schizophrenia: Not associated with exacerbation of psychosis. Depression: Mixed evidence regarding exacerbation of depressive symptoms.

15. Some �real life� evidence In an observational study comparing NRT with varenicline 412 smokers seeking treatment (111 with mental illness) from a UK NHS stop smoking clinic Validated short-term quit rates Results showed: Varenicline was superior to NRT Varenicline equally effective in mentally ill and non-mentally ill persons No worsening of mental illness observed.

16. Making NRT more available Increased range and capacity of cessation services Improving referral systems between primary/secondary care and cessation services Training in ABC Improving data collection and feedback Other initiatives underway Other initiatives underway

17. ABC Training Non prescribers can register as quit card providers at the end. Prescribers can access more quit cards. Non prescribers can register as quit card providers at the end. Prescribers can access more quit cards.

18. Smoking is too big to ignore