Intervention Strategies for Tobacco and Behavioral Health

1. Intervention Strategies for Tobacco and Behavioral Health Steven A. Schroeder, MD May 19, 2014 Presentation courtesy of The Smoking Cessation Leadership Center and Rx for Change

2. Conflict of Interest?

4. Smoking Prevalence by MH Diagnosis 2007 NHIS data • Schizophrenia 59.1% • Bipolar disorder 46.4% • ADD/ADHD 37.2% Current smoking: • 1 MH 31.9% • 2 MH 41.8% • 3+ MH 61.4% Grant et al., 2004, Lasser et al., 2000 • Major depression 45-50% • Bipolar disorder 50-70% • Schizophrenia 70-90%

5. Smoking Prevalence and Average Number of Cigarettes Smoked per Day per Current Smoker 1965-2010* Percent/Number of Cigarettes Smoked Daily * Schroeder, JAMA 2012; 308:1586

6. Myths About Smoking and Mental Illness* • Tobacco is necessary self-medication (industry has supported this myth) • They are not interested in quitting (same % wish to quit as general population) • They can’t quit (quit rates same or slightly lower than general population) • Quitting worsens recovery from the mental illness (not so; and quitting increases sobriety for alcoholics) • It is a low priority problem (smoking is the biggest killer for those with mental illness or substance abuse issues) * Prochaska, NEJM, July 21, 2011

7. WHY HELP MENTAL HEALTH CONSUMERS QUIT? 1 Improve health and overall quality of life Increase healthy years of life Improve the effect of medications for mental health problems Decrease social isolation Help save money by not buying cigarettes Quitting smoking helps recovery 2 3 4 5 6

8. Covered Benefits under ACA* • 4 counseling sessions of at least 10’ each (including telephone, group &/or individual • All FDA approved tobacco cessation medications, including both RX and OTC • Offered at least twice yearly • No prior authorization required. • No co-pays, co-insurance, or deductibles * 2014

9. System Elements for Cessation Programs* • Identification of smokers • Training (clinicians and other staff) • Dedicated staff for cessation • Include cessation effort in staff evaluation • Promote hospital and clinic policies * AHRQ

10. Lessons Learned at SCLC • Identify and support local champions • Need to identify smoking status (EHR) • Involve and train office/hospital staff • Measure intervention frequency and give feedback • Include in consumer satisfaction surveys • Help staff to quit (key for BH settings) • Policies for smoke-free environments • Peer support and counseling

11. 2013 Common Strategy Groups for 8 SAMHSA Academy States • Quitline referrals • Data Development • Communication • Provider Education • NC is a leader

12. Los Angeles County CPPW* Pioneers SCLC worked with LA County on its CPPW grant Community-based organizations (CBOs), called LA Pioneers, were tasked with making policy changes and implementing tobacco cessation protocols as part of plan to be a smoke free site and effect systems change SCLC held specialized webinars, monthly phone calls, created custom toolkit, and conducted site visits to provide support and resources to the LA Pioneers Pioneers provided cessation services to clients and staff * Communities putting prevention to work

13. Los Angeles County CTG* Champions SCLC is currently working with LA County on CTG Similar to the CPPW project, but this grant is focused solely on behavioral health (BH) organizations providing both inpatient and outpatient services LA CTG champions were tasked with making policy changes and implementing tobacco cessation protocols (for both clients and staff) as part of plan to become a smoke free campus Again, SCLC held specialized webinars, monthly phone calls, created custom toolkit, and conducted site visits to provide support and resources to the LA champions * Community transformation grant

14. The National Quitline Card —

16. Online Smoking Cessation Assistance www.becomeanex.org • Online smoking cessation services now available for smokers who prefer using computers over telephones • Anonymity is a plus, as with telephone quitlines • Early studies show promising efficacy • www.quitnet.com • www.smokefree.gov • www.becomeanex.org

17. Tips for Your Office • Referral forms to the quitline (1-800-QUITNOW) • Carbon monoxide breathalyzer (cost about $500 plus disposal mouthpieces) • One key question to ask: “When do you have your first cigarette of the day?” • Approach smoking as a chronic illness

18. Top 10 SCLC Milestones, 2003-2013 • Helping incorporate smoking cessation into mainstream treatment of CMI and SA disorders • Productive partnerships with health professional societies to promote SC • Ask, Advise, Refer as acceptable SC strategy, and marketing 1-800-QUITNOW

19. Top SCLC Milestones (2) • Marketing Rx for change curriculum • SCLC educational offerings • Collaborative work with SAMHSA • Place-based initiatives • Helping Pfizer with a $4.5m SC grants program (39 grantees) • Amplifying voices of cessation champions • Multiple articles in scientific literature

20. Knowledge Gaps Re Smoking Cessation • Most studies supported by pharma • Important populations omitted by pharma: --behavioral health --light and intermittent smokers --incarcerated persons --youth --pregnant women

21. Cessation Knowledge Gaps (2) • Optimal length of cessation drug treatment (FDA says 12 weeks) • Natural history of quit attempts • Menthol! • Epidemiology of quitline outreach • Gender and ethnic differences— no data so far that approach should vary

22. The Electronic Cigarette * • Aerosolizes nicotine in propylene glycol • Cartridges contain about 20 mg nicotine • Safety unproven, but >cigarette smoke • Bridge use or starter product? • Probably deliver < nicotine than promised • Not approved by FDA • My advice: avoid unless patient insists * Cobb & Abrams. NEJM July 21, 2011; Fiore, Schroeder, Baker, NEJM Jan 23, 2014

23. Smoking Profile, 2014 • Most clinicians and policy makers live in a non-smoking “gated community” • Smoking now marginalized to the poor and the disadvantaged, plus some “young immortals” • Thus tobacco control=social justice issue • Tobacco industry fights domestic rear guard action while expanding overseas

24. Q and A

25. SCLC Top 10 Wish List (Emerging Directions) 2014-- • Continued work with BH professionals, including military and Dept. of Defense • Continued work with targeted health professionals • Extend the reach of quitlines • Ban cigarette sales from pharmacies (!!!) • Reduce tobacco use by college students • Include SC in AA and other 12 step programs

26. SCLC Top Ten Wish List (2) • Expand work with HRSA • Further adoption of Joint Commission/NQF tobacco core measures • Address tobacco use among low SES and disabled persons in low income housing • Criminal justice involved populations

27. A Tale of Two Cancers—Lung vs. Breast • Many more deaths from lung cancer for both genders, but even just for women • Yet more attention, including NIH research $, devoted to breast cancer; no race for the cure or brown ribbon • Reasons --different advocacy levels (stigma) --lack of public spokeswoman --fewer lung cancer survivors

28. Reasons for Not Helping Patients Quit 1. Too busy 2. Lack of expertise 3. No financial incentive 4. Lack of available treatments and/or coverage 5. Most smokers can’t/won’t quit 6. Stigmatizing smokers 7. Respect for privacy 8. Negative message might scare away patients 9. I smoke myself 10.Electronic medical record system problems (EPIC)

29. Medications Affected by Smoking Brand NameGeneric Name ElavilAmitriptyline AnafranilClomipramine Aventyl/PamelorNortiptyline TofranilImipramine LuvoxFluvoxamine Thorazine Chlorpromazine ProlixinFluphenazine Haldol Haloperidol ClorizarilClozapine ZyprexaOlanzapine Tylenol Acetominophen InderalPropanolol Slo-bid, Slo-Phyllin, Theophylline Theo-24, Theo-Dur, Theobid, Theovent Caffeine

30. Financial Impact *Steinberg, 2004 People with mental illnesses and/or addictions may spend up to 1/3 their income on cigarettes* A pack a day smoker spends on average… $6.50 per day $45.50 per week $198.00 per month $2,372.50 per year $23,725.00 per 10 years