Are the 5A's Enough?: Tobacco Dependence Treatment for Smokers with Mental Illness

1. Are the 5A's Enough?: Tobacco Dependence Treatment for Smokers with Mental Illness National Conference on Tobacco or Health October 25, 2007

2. The Panelists • Wendy Bjornson, OHSU, TCLN • Eric Heiligenstein, UW-Madison • Gary Tedeschi, UCSD, CSSH • Jonathan Foulds, UMDNJ School of Public Health • Connie Revell, UCSF, SCLC

3. Our Aim • A brief overview of mental health and smoking cessation • How to tailor cessation services for this population • Promising practices and case studies • New resources available • New strategies for reaching this underserved population

5. Reaching Smokers with Mental Illness and Substance Use Disorders Wendy Bjornson, MPH Director, Tobacco Cessation Leadership Network Funded by the American Legacy Foundation

6. Relationship of Smoking, Mental Illness and Substance Use Disorders • People with mental illness and substance use disorders consume 45% of cigarettes smoked in U.S.1 • Rates of smoking are 2-4 times higher than among the general population.2 • Nearly 41% of current smokers report having a mental health diagnosis in the last month.3 • 60% of current smokers report a past or current history (ever history) of a mental health diagnosis sometime in their lifetime.2 1 Breslau, 2003, 2. Kalman, 2005 3. Lasser, 2000

7. Smoking Rates Compared to the Number of Lifetime Psychiatric Diagnoses Adapted from Lasser, 2000

8. Bringing Everyone Along • Help address a growing need within tobacco dependence treatment to better serve clients with mental health and substance use disorders. • Aim is to: • Combine existing literature with professional experience (gathered through online and interview surveys) into a Resource Guide. • Disseminate the Resource Guide to key audiences; • Provide training and technical support to help adapt programs to better assist patients/clients with mental illness and substance use disorders.

9. Online Survey • Online surveys were sent to 3 tobacco cessation professional groups identified and selected for participation. • Tobacco Cessation Leadership Network (TCLN). • Association for Tobacco Use and Dependence (ATTUD). • North American Quitline Consortium (NAQC). • 104 Online surveys completed. • Respondents from public health agencies, alcohol and substance abuse treatment programs, mental health agencies, tobacco dependence treatment programs, and others.

10. Interview Survey • Population drawn from online survey. • 28 interviews were completed. • Respondents were from: • Tobacco treatment programs with tailored substance abuse and mental health protocols. • Quitlines. • Mental health programs that include tobacco dependence treatment. • Substance abuse programs that include tobacco dependence treatment.

11. BEA Expert AdvisorsInterpretation of Survey Data and Program Recommendations

12. Summary: Reaching Tobacco Users Referral Quitlines Health care Tobacco user Referral Referral Community Cessation Programs

13. Referral Health care Quitlines Referral Referral Tobacco user Mental Health Facilities Substance Use Facilities Community Cessation Programs Referral Summary: Reaching tobacco users with mental illness and substance use disorders Referral

14. Summary: Trends and Gaps

15. Seven Recommendations for All Programs • Change old beliefs. • Belief still exists that tobacco users with mental illness and substance use disorders don’t want to or can’t quit. • These beliefs are outdated and serve as barriers, even preventing treatment from being offered. There is ample evidence that they both want to and can quit. • Provide tailored and more intensive treatment programs. • Programs and services need to be tailored both behaviorally and pharmacologically to the specific needs of the patient/client and to their usual treatment setting. • Coordination among the key care providers is necessary for integrated care. • Referral networks and/or partnerships between primary care providers, quitlines, tobacco treatment specialists, and mental health and substance use professionals are necessary.

16. Seven Recommendations for All Programs • Use a comprehensive assessment to tailor services. • Tailoring treatment services and referrals is based on an initial individualized, detailed assessment. • Training is needed to complete the assessment, determine functional status, and make appropriate treatment and referral decisions. • Recommend cessation pharmacotherapy; monitor psychiatric medications. • Most will need cessation pharmacotherapy. • Smoking cessation can increase effect of some psychiatric medications. Monitoring of symptoms is important; potential dose adjustment may be needed.

17. Seven Recommendations for All Programs • Tailor behavioral treatment. • Often need more intensive behavioral treatment, e.g. more and longer sessions, more follow-up. • Often need protracted preparation time prior to quitting. Need more education and time to master coping skills. • Need flexibility; predetermined schedules for quitting and follow up may be too structured. • Increase training and supervision for counseling staff. • Treatment specialists need to make clinical judgments, have more contact with healthcare providers, participate in case management, and make referrals. • Survey shows: • More training increased comfort in assessing symptoms and previous history directly. • Less training caused discomfort, sometimes avoidance.

18. Seven Recommendations for All Programs • Consider the effect of smoke-free policies. • Smoke free/tobacco-free policies drive increase in development of services for mental health and substance use facilities. • Smoke free policies increase demand from clients with mental illness and substance use disorders.

19. BEA Resource Guide • Content • Section One: overview ofdevelopment process. • Section Two: Summary and recommendations of Expert Advisory Committee. • Section Three: expert advice for each treatment setting. • Tobacco cessation programs in community settings; • Tobacco quitlines; • Tobacco cessation services in mental health settings; • Tobacco cessation services in substance abuse settings. • Section Four: toolkits, resources, references. • Training and technical support • TCLN/BEA conference call series, winter 2007/2008 • Workshops, 2008 • www.tcln.org/bea

20. BEA Expert Advisory Committee

22. Are the 5 A’s Enough? Tobacco Dependence Treatment for Smokers with Psychiatric Disorders Eric Heiligenstein, M.D. University Of Wisconsin-Madison

24. Smoking Cessation Activities of Psychiatrists • Identify and document smoking status (Ask); 35% (90) • Advice to Quit; 60% (71) • Assess willingness to quit; 40% (56) • Assist; 10-30% (49) • Arrange follow up; 0% (9) Price, 2007; Quinn, 2005

25. Smoking Cessation Activities Child/Adolescent Psychiatrists • Identify and document smoking status (Ask); 14% (90) • Advice to Quit; 30% (71) • Assess willingness to quit; 18.5% (56) • Assist; 1-33% (49) • Arrange follow up; 8-10% (9) Price, 2007; Quinn, 2005

26. Preparation of Psychiatry Residents for Treating Nicotine Dependence • Training in tobacco cessation • Medical school; 26% • Residency; 21% • Interest in learning more about helping their patients to quit; 94% Prochaska, 2005

27. Smoking Cessation Activities Psychologists • Ask; Often=8%, Never=41% • Advice to Quit; Often=9%, Never=48% • Give cessation support; Often=1, Never=81% Hjalmarson, 2004

28. Smoking Cessation Activities Psychologists • Identify and document smoking status (Ask); 20% • Identification added as “vital sign”; 87% Heiligenstein, 2004

29. Perceived Barriers to Using the 5 A’s • Lack of time • Patients do not want to quit • Preoccupation with other problems • Low confidence in provider’s ability to help • Lack of familiarity with treatment resources Price, 2007 Heiligenstein, 2004

31. Necessary Mental Health Care System Interventions (5 A’s) • Inservice training of mental health staff • Integration of smoking cessation best practices into training programs • Requiring smoking status as a “vital sign” • Chart reminders on how to move patients through stages of change • Development of comprehensive intervention resources

36. Bringing Everyone Along:The Role of Quitlines Gary J. Tedeschi, Ph.D. University of California, San Diego California Smokers’ Helpline

37. Comorbidity in a Quitline setting • Depressive disorder • Bipolar disorder • Manic-depression (older term) • Thought disorder • e.g., Schizophrenia • Anxiety disorder • Post traumatic stress disorder (PTSD) • Other chemical abuse/dependency • e.g., Drug, alcohol

38. Assessment • At intake or counseling? • Type of assessment • Client report • Psychiatric treatment question • Medication question • Other diagnostic questions/instruments

39. Treatment Considerations • Is the quitline an appropriate setting? • Level of functioning • Concurrent psychiatric treatment • If yes, provide cessation treatment • Client contact with prescribing physician • Clinical supervision • If no, provide referral for psychiatric treatment • Proactive follow-up • Reassessment

40. Quitline as Portal to Other Services • Refer back to primary care provider and/or mental health treatment provider • Identify mental health care providers in community with expertise in addictive behavior • Assist client in finding mental health services in local area

41. Conclusion • Clients with psychiatric health issues call Quitlines. • Clients with psychiatric health issues have different levels of functioning. • Quitlines can serve this clientele based on client level of functioning & local professional support: • Full protocol • Single session and referral • Referral

43. People With Mental Health and Addiction Problems – The Forgotten Smokers? Jonathan Foulds PhD Director, Tobacco Dependence Program UMDNJ-School of Public Health Jonathan.foulds@umdnj.edu www.tobaccoprogram.org 732-235-8213

44. Why Forgotten? • 40 years of reducing smoking rates EXCEPT for smokers with mental illness or addiction • Unidentified high risk group? • Little data on tobacco use in this group • Little data on tobacco-caused disease in these groups • Assumption: they don’t really want to quit? • Assumption: none of them are able to quit? • Assumption: their behavioral health problems will worsen if they give up tobacco • False beliefs and Stigma leads to no change

45. Barriers to Addressing Smoking • Provider Resistance • Patient Resistance • Family Resistance • Concern about exacerbation of symptoms, relapse, and increased acting out • Concern about interaction with psych meds • Easy Access • Taking away their only pleasure

46. Consequences & Costs of Not Treating Tobacco in the Behavioral Health System • Increased Mortality • Increased Morbidity • Increased use of health care resources • Decreased Quality of Life • Increased Societal Costs, including costs to employers

47. This is a health disparity issue • A sizeable segment of the population is consuming tobacco 2-3x the rate of the rest of the population. • The system in which they receive care currently does little to change tobacco use. • The behavioral health system needs a radical change to solve this problem. • Tobacco control has largely ignored this issue

48. This is a systems issue affecting many more than just the clients • Smoking prevalence is high among staff in the behavioral healthcare system and their families • It also has a knock-on effect on the families of clients in the behavioral healthcare system • It is the system and the culture within the system that needs to be changed. This will create a lasting effect.

49. Barriers to Tobacco Dependence Treatment • Lack of staff training • “not my role” – go to primary care • Staff fear that patient’s will misuse NRT or smoke while taking NRT • Staff who smoke – normalize smoking, staff may help patient’s access cigarettes, program may sell cigarettes • Restrictive formulary or coverage of the cost of medications • Limited income and cannot afford OTC medications

50. The Steps for Becoming a Tobacco-Free Facility