Behavioral Health is Essential To Health, Prevention Works, Treatment is Effective, People Recover

1. Behavioral Health is Essential To Health, Prevention Works, Treatment is Effective, People Recover

2. Freedom from Tobacco: Providing Education to SupportWellness Lifestyle Changes SAMHSA Wellness Initiative May 22, 2012

3. Disclaimer • The views expressed in this training do not necessarily represent the views, policies, and positions of the Center for Mental Health Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), the U.S. Food and Drug Administration (FDA), or the U.S. Department of Health and Human Services (HHS).

4. Steven A. Schroeder, M.D. Professor of Health and Healthcare,Department of Medicine Director, Smoking Cessation Leadership Center University of California, San Francisco

5. Tobacco Freedom: Living Well by Making Healthy Lifestyle Choices Steven A. Schroeder, M.D. Professor of Health and Healthcare, Department of Medicine Director, Smoking Cessation Leadership Center University of California, San Francisco

6. Tobacco’s Deadly Toll • 443,000 deaths in the U.S. each year* • 4.8 million deaths worldwide each year • 10 million deaths estimated by year 2030** • 50,000 deaths per year in the U.S. due to second-hand smoke exposure • 8.6 million disabled from tobacco in the U.S. alone* • 46.6 million smokers in U.S. (78 percent are daily smokers)* Sources: * Centers for Disease Control and Prevention.(2011). National Center for Chronic Disease Prevention and Health Promotion. ** Estimated from 2005–2030. World Health Organization Report on the Global Tobacco Epidemic, 2008.

7. Source: Centers for Disease Control and Prevention. (2008). Morbidity and Mortality Weekly Report (MMWR); 57, p. 1226–1228. Annual U.S. Deaths Attributable to Smoking, 2000–2004 7

8. Cancers Acute myeloid leukemia Bladder and kidney Cervical Esophageal Gastric Laryngeal Lung Oral cavity and pharyngeal Pancreatic Prostate (↑incidence and ↓survival) Pulmonary diseases Acute (e.g., pneumonia) Chronic (e.g., COPD) Cardiovascular diseases Abdominal aortic aneurysm Coronary heart disease Cerebrovascular disease Peripheral arterial disease Type 2 diabetes mellitus Reproductive effects Reduced fertility in women Poor pregnancy outcomes (e.g., low birth weight, preterm delivery) Infant mortality; childhood obesity Other effects Cataracts, osteoporosis, periodontitis, poor surgical outcomes, Alzheimer’s Source: U.S. Department of Health and Human Services. (2004). The Health Consequences of Smoking: A Report of the Surgeon General. Health Consequences of Smoking 8

9. Quitting: Health Benefits Note: CHD=Coronary Heart Disease 9

10. Developmental Low birth weight Sudden infant death syndrome (SIDS) Pre-term delivery Childhood depression Respiratory Asthma induction and exacerbation Eye and nasal irritation Bronchitis, pneumonia, otitis media in children Decreased hearing in teens Carcinogenic Lung cancer Nasal sinus cancer Breast cancer (younger, premenopausal women) Cardiovascular Heart disease mortality Acute and chronic coronary heart disease morbidity Altered vascular properties Causal Associations with Second-hand Smoke Source: U.S. Department of Health and Human Services. (2006).The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General. 10

11. Smoking Prevalence and Average Number of Cigarettes Smoked per Day per Current Adult Smoker1965–2010 Source: Centers for Disease Control and Prevention. (1965–2010). National Health Information Survey. 11

12. Smoking and Mental Illness: The Heavy Burden • 200,000 annual deaths from smoking occur among people with serious mental and/or substance abuse disorders. • This population consumes 44 percent of all cigarettes sold in the U.S. • Higher prevalence • Smoke more • More likely to smoke down to the butt • People with serious mental illness die on average 25 years earlier than others. • Smoking is a large contributor to that early mortality • Social isolation from smoking compounds the social stigma. 12

13. Smoking Prevalence by Mental Health Diagnosis Current smoking • 1 mental health diagnosis 32% • 2 mental health diagnoses 42% • 3+ mental health diagnoses 61% 2007 National Health Interview Survey Data • Schizophrenia 59% • Bipolar disorder 46% • ADD/ADHD 37% Grant et al., 2004, Lasser et al., 2000 • Major depression 45–50% • Bipolar disorder 50–70% • Schizophrenia 0–90% 13

14. Smoking PrevalenceAmong Other Populations • Addiction treatment centers–ranges from 53 percent to 91 percent • (Guydish et al., Nicotine and Tobacco Research, June 2011, p. 401) • Prisons–81 percent • (Kauffman et al., Nicotine and Tobacco Research, June 2011, p. 449) 14

15. Myths AboutSmoking and Mental Illness • MYTH: Tobacco is necessary self-medication. • TRUTH: It is not. The tobacco industry has supported this myth. • MYTH: They are not interested in quitting. • TRUTH: The same percentage wishes to quit as in the general population. • MYTH: They can’t quit. • TRUTH: The quit rates are the same or slightly lower than the general population. • MYTH: Quitting worsens recovery from the mental illness. • TRUTH: Not true. • MYTH: It is a low-priority problem. • TRUTH: Smoking is the biggest killer for those with mental and/or substance abuse disorders. Source: Prochaska, J. J. (2011). New England Journal of Medicine. July 21, 2011.

16. Myths aboutSmoking and Addictions • MYTH: Quitting conflicts with drug abuse or alcohol treatment. • TRUTH: If you stop smoking, you are more likely to remain clean and sober. • MYTH: Addicts don’t want to quit. • TRUTH: Many do. • MYTH: Addicts can’t quit. • TRUTH: Many can. • MYTH: Quitting jeopardizes recovery. • TRUTH: On the contrary, quitting can help recovery. Source: Schroeder and Morris. (2010). Annual Review of Public Health. 16

17. Ask. Advise. Refer. = 5 A’s 17

18. Caveats About Cessation Literature • Smoking should be thought of as a chronic condition, yet drug treatment is often short (12 weeks) in contrast to methadone maintenance. • There is a great spectrum of severity and addiction; treatment should be tailored accordingly. • Volunteers for studies are likely to be more motivated to quit. • Placebo and drug groups tend to have more intensive counseling than found in real practice world. • Most drug trials exclude patients with mental illness. 18

19. Long-term (6 month) Quit Ratesfor Available Smoking Cessations Data adapted from: Cahill et al. (2008). Cochrane Database of Systematic Reviews (CDSR). Stead et al. (2008). Cochrane Database of Systematic Reviews (CDSR). Hughes et al. (2007). Cochrane Database of Systematic Reviews (CDSR). 19

20. Why the Focus on Quitlines? • They work. Calling a quitline can more than double the chance of successfully quitting. • Many clinicians say the 5A’s are too complicated and time-consuming. • Most clinicians are unaware of quitlines; when they learn about them, they are willing to refer smokers to them. 20

21. Addiction and Mental DisordersAmong Quitline Callers • Several studies have found that people with behavioral health issues may use quitline services more frequently and have outcomes very similar to the general population.* • The prevalence of current mental illness among quitline callers ranges from 19 percent to 50 percent. ** • Approximately half (48.9 percent) of callers report having at least one mental health issue.*** Sources: *Colorado Department of Public Health and Environment, 2009 unpublished data; Hrywna et al., 2007; Kreinbring & Dale, 2007; Tedeschi et al., 2009: Zhu et al., 2009 unpublished data. **Canadian Smokers’ Helpline, 2009 unpublished data; Hrywna et al., 2007; Kreinbring & Dale, 2007; McAfee, Tutty, Wassum, & Roberts, 2009; Tedeschi, Zhu, & Herbert, 2009). ***Zhu et al., 2009 unpublished data. 21

22. Self-Reported Mental Health IssuesAmong Callers Source: Zhu,et al., 2009. Unpublished data 22

23. Tobacco Treatment Findingsfrom Quitline Survey Responses Source: Zhu,et al., 2009. Unpublished data. *Descriptive data, not based on results of a randomized controlled trial 23

24. Community Referrals • Quitlines are most effective when working in coordination with other providers. • Formal partnerships and referral mechanisms: • May decrease client ambivalence • Give clinicians more confidence in clients’ follow through • Lead to an increase in quitline utilization 24

25. Resources • Toll-free 1–877–509–3786 for smoking cessation technical assistance • Smoking Cessation Leadership Center Catalogue of Tools • SCLC behavioral health resources: http://smokingcessationleadership.ucsf.edu/MH_Resources.htm • Smoking Cessation curriculum: http://rxforchange.ucsf.edu 25

26. Meghan Caughey, M.A., M.F.A Senior Director of Peer and Wellness Services Cascadia Behavioral Healthcare

27. Freedom from Tobacco Meghan Caughey, M.A., M.F.A Senior Director of Peer and Wellness Services Cascadia Behavioral Healthcare

28. Big Surprise • I was a smoker and did not know it! • Started smoking during time in an inpatient unit as the only way to go outdoors. • Psychiatric experience created a reason to smoke. • Harmful relationship by helping people to develop tobacco addictions during inpatient care. 28

29. Self-Image of Persons with Lived Experience • Persons with lived experience see themselves as: • “Rebels” from the system if smoking • Younger than their peers if smoking 29

30. Is Smoking a Personal Right? • Do we have the right to hurt ourselves? • To smoke? • To develop chronic illnesses, such as heart disease? • Do we care if our peers hurt themselves? 30

31. We Are All Interconnected! • If we hurt ourselves, we are hurting everyone else as well. 31

32. Exciting Motivation “We cannot push or lead someone into motivation. We can, with understanding, create conditions that potentially excite motivation.” —Patricia Deegan, Ph.D. 32

33. Linking Care for Trauma and Wellness • Trauma-informed care must be practiced in concert with wellness-informed care! • We should ask, “What happened to this person that has led to these lifestyle choices?” • Consider the relationship role tobacco may play in their lives and why. • “Cigarettes were my best friend,” said a peer who stopped smoking after 20 years. 33

34. Role of Coercion in Mental Health Treatment Settings • Freedom from coercion and freedom from smoking are linked. • We must look more closely at the role of coercion in mental health settings. • Supporting policy work to make hospitals and treatment facilities smoke-free is critical. 34

35. Peer Support Services Are Vital • To non-smoking peer culture, peer support services are vital. 35

36. Sideways Approachto Smoking Cessation • Top-down approach to smoking is very limited. • We need a “sideways” approach that includes both trauma- and wellness-informed care services. • We cannot push and shove each other into wellness. 36

37. Resources • Bringing Everyone Along • Tobacco Cessation Network - http://www.tcln.org/bea • Williams, J. M., Ziedonis, D. M., Speelman, N., Vreeland, B., Zechner, M., Rahim, R., O’Hea, E. Learning about Healthy Living: Tobacco and You Manual. Revised June 2005. Supported by a grant from the New Jersey Division of Mental Health Services. • Tobacco-Free Living in Psychiatric Settings (NASMHPD) • http://www.nasmhpd.org/general_files/publications/NASMHPD.toolkitfinalupdated90707.pdf • The Adverse Childhood Experiences (ACE) Study • http://www.cdc.gov/ace 37

38. Jonathan Foulds, Ph.D. Professor of Public Health Sciences and Psychiatry Penn State University, College of Medicine

39. Helping Smokers To Quit in Behavioral Healthcare Jonathan Foulds, Ph.D. Professor of Public Health Sciences and Psychiatry Penn State University, College of Medicine

40. Helping Smokers To Quitin Behavioral Healthcare • To not properly address tobacco dependence in your patients only adds to the stigma they already face. • Who better to treat tobacco dependence and withdrawal that trained mental health clinicians? • Tobacco dependence should be treated as a chronic illness. Work on it until you have long-term success. • Tobacco is a systems issue for the entire behavioral healthcare system. • There are plenty of resources to help you. 40

41. 5 A’s (and an R) of Smoking Cessation • ASK::Do you use any tobacco products? • ADVISE: “As your clinician I want to advise you that the single best thing you can do for your health is to quit smoking. We have new, more effective treatments and I would like to help. • ASSESS: Motivation and dependence • Do you have any interest in quitting smoking? • How many cigarettes per day do you smoke? • How many minutes after waking do you smoke your first cigarette of the day? • ASSIST: Make a plan. Offer medication advice and counseling support: 1–800–QUIT–NOW (1–800–784–8669) or http://www.smokefree.gov. • ARRANGE: Follow-up to monitor progress and side effects. • RE-TREAT: If they go back to smoking. 41

42. If 5 A’s Do Not Work … Repeat • It’s time to treat tobacco dependence the same way we treat other chronic illnesses (e.g., hypertension). • If the patient doesn’t initially succeed, continue to work with them until they do. • Re-treat with more intensive treatment or refer on to specialist services, until the patient successfully quits. 42

43. Medication Interactionswith Tobacco Smoke • Smoking causes↑ P450 enzyme system • This is caused by toxins in the smoke/tar • Smoking therefore causes↑ metabolism of some meds • ↓ serum levels • Smokers typically on higher medication doses 43

44. Smoking Causes Some Drugsto be Metabolized Faster Antipsychotics Olanzapine Clozapine Fluphenazine, Haloperidol, Chlorpromazine Antidepressants Amitriptyline, doxepin, clomipramine, desipramine, imipramine, fluvoxemine Others Caffeine, theophylline, warfarin, propranolol, acetaminophen 44

45. Risk for medication toxicity May ↑ levels acutely Consider dose adjustment Clozapine toxicity Seizures may result Reduce caffeine intake Nicotine (or NRT) does not change medication Levels Nicotine metabolized by CYP2A6 Implications for Quitting Smoking 45

46. 2008 U.S. Public Health ServiceClinical Practice Guidelines (Fiore et al.) 46

47. Time to Smoking Relapse in Substance Use PatientsTreated Concurrently for Alcohol and Tobacco withNicotine Replacement Therapy (Patch +) and Weekly Counseling This chart shows the results of a similar trial in patients with alcohol problems. Very similar pattern in patients with co-occurring alcohol problems, particularly up to 90 days (when patch treatment ended). Source: Cooney et al., 2009. 47

48. Varenicline versus Placebo in Schizophrenia 7-Day Point Prevalence of Abstinence from Smoking (Williams et al., 2012) Analysis population = ITT minus one subject randomized to varenicline who did not receive treatment CI=confidence interval; ITT, intent to treat; OR=odds ratio 48

49. Barriers to Tobacco Dependence Treatment • Lack of staff training • Staff who believe it is not their role and send patients to primary care for help • Staff fear that patients will misuse nicotine replacement therapy (NRT) or continue to smoke while taking NRT • Staff who smoke normalize smoking and who provide patients access to cigarettes • Program selling cigarettes to patients • Restrictive formulary or coverage of the cost of medications • Limited income and cannot afford over-the-counter medications 49

50. What Do We Know About Treating Tobacco in Behavioral Health Treatment? • Tobacco treatment can be successfully integrated into behavioral health treatment. • Most clients want to address tobacco. • Treating tobacco does not cause clients to leave treatment early. • The greatest resistance often comes from staff. • Tobacco-free grounds policies are challenging to implement, but create a sustainable culture. • NRT helps treat withdrawal symptoms. • Now is the time for behavioral services to treat tobacco with the seriousness it deserves. 50