Annette Bradfield Kerri-Anne Mullen Donna Pettey Derrick Shears Gordon Stevenson

1. Providing Smoking Cessation to those with Serious Mental Illness: PSR/RPS Canada ConferenceOttawaSeptember 22nd, 2010 Annette Bradfield Kerri-Anne Mullen Donna Pettey Derrick Shears Gordon Stevenson

2. Learning Objectives for the Session • To provide an understanding of the clinical correlates and prevalence of smoking related illnesses • To address the systemic, historic and educational barriers to providing smoking cessation interventions to this population • To describe successful smoking cessation interventions with a specific case study presentation of a current program providing smoking cessation to individuals with serious mental illness

3. Canadian Mental Health Association Ottawa: Our Historical Roots Serving the greater Ottawa area for over 50 years, founded 1953 2010 budget >$10.5 million/ 100+employees Funding from: Province of Ontario, City of Ottawa, United Way, donations

4. Why is Tobacco Use of Concern to a Mental Health Agency? • Individuals with severe mental illness die twenty-five years earlier than the general population • Sixty percent of these deaths are due to cardiovascular and respiratory disease • For individuals with schizophrenia, heart disease is now associated with twenty-five to thirty years premature mortality

5. Why is Tobacco Use of Concern to a Mental Health Agency? • Up to 85% of individuals with severe mental illness continue to use tobacco products • 40% smoke more than forty cigarettes a day • Individuals with mental illness comprise 44.3% of the U.S. tobacco market accounting for 39 billion dollars in annual sales.

6. A Canadian study that examined mortality rates among the homeless and marginally housed concluded the probability of survival to age 75 for those living in the marginal housing environments was: • 32% for men and 60% for women (compared with 51% and 72% respectively for those in even the lowest Canadian income percentile) • The largest differences in the mortality rates were for smoking related heart and respiratory diseases.

8. Over the past 40 years, population health interventions that address smoking in the general population have been remarkably successful….

12. Over the past 40 years, population health interventions that address smoking for those with a Serious Mental Illness or an addiction have been absent as prevalence rates have climbed or remained elevated….

13. Why would this be? A range of individual and system factors that help to explain why this vulnerable population continues to smoke at alarming levels, specifically that the “prioritization of mental health treatment, lack of an appreciation of the health effects of cigarette smoking, and beliefs among clinicians that persons with mental illness are not able or willing to quit have contributed to a culture in many treatment settings that accepts and ‘normalizes’ cigarette smoking” (Hall & Prochaska, 2009. p. 411)

14. Smoking Prevalence and Nicotine Dependency Data at CMHA • Survey of active CMHA clients between May 11th and May 31st 2010 • 639 clients (or 89% of all active clients of the agency) reported if they smoked or not • 445 reported smoking tobacco and 194 reported they were non smokers • 307 clients (or 69% of the 445 smokers) completed the Fagerstrom Nicotine Dependency Assessment

24. Where do we go from here Develop an overall agency strategy to respond to the treatment needs of clients: • Clinical services • Discussion Paper

25. An Effective Clinical Approach to Smoking Cessation

26. Smoking Cessation The single, most powerful preventive intervention in clinical practice

27. Olivier, Lubman, Fraser. Australian and New Zealand Journal of Psychiatry 2007; 41. “Although in terms of lives saved, quality of life, and cost efficacy, treating smoking is considered to be one of the most important activities a clinician can undertake… psychiatrists seldom discuss the issue with their patients”

28. Smoking is The Leading Preventable Cause of Disease and Death in Canada Cardiovascular Ischemic heart disease (#2)Stroke – Vascular dementia Peripheral vascular disease Abdominal aortic aneurysm Respiratory COPD (#3) Pneumonia Poor asthma control Cancer Lung (#1) Oral cavity/pharynx Laryngeal Esophageal Stomach Pancreatic Kidney Bladder Cervical Leukemia Active Smoking Reproductive Low birthweight Pregnancy complications Reduced fertility SIDS Other Adverse surgical outcomes/ wound healing Hip fractures Low bone density Cataract Peptic ulcer disease

30. Nicotine Addiction Nicotine rewards smoking Nicotine alters the brain Psychological and social forces are at work Dopamine release Signal to notice and repeat Acquired ‘drive’ (hunger) Urge to smoke if abstinent for a while Reminders (cues) increase urge Pairing of stimuli Beliefs about stress control Identity Camaraderie Adapted from McEwen et al, Manual of Smoking Cessation 2006

31. Nicotine Withdrawal Withdrawal Syndrome Irritability, frustration, or anger Insomnia/sleep disturbance Anxiety (may increase or decrease with quitting) Increased appetite or weight gain Dysphoric or depressed mood Restlessness or impatience Difficulty concentrating American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision. Washington, DC: American Psychiatric Association; 2000.

32. In-patients with Mental Illness & Cessation • Large numbers of smokers • Length of stay • Relevance of smoking to disease • Availability of staff • Opportunity for systematic approach • Availability of pharmacotherapies - treatment of withdrawal • Attachment to follow-up • Influence community practice

33. “The Ottawa Model” Identification Documentation Counseling Pharmacotherapy Long-term follow-up Reid RD, Pipe AL, Quinlan B. Can J Cardiol 2006;22:775-780

34. 70 sites across Canada, 3 Centres of Excellence

35. (OR = 1.71; 95% CI = 1.11, 2.64; Z = 2.43; I2 = 0%; P = 0.02). Ottawa Model effectiveness in 9 Ontario hospitals

38. Adaptation → Adoption Phase 1.0 Gaining commitment Phase 3.0 Training key contacts Phase 4.0 Phase 5.0 Training front-line Delivering service Phase 2.0 Revising policies Assessing the environment Planning for action Preparing supports Phase 6.0 Measuring results Gathering data

40. The Ottawa ModelConsult Form

42. Pharmacotherapy for Tobacco Dependence • Nicotine replacement therapy (NRT) • Long acting • Patch • Short acting • Gum • Inhaler • Lozenges • Bupropion SR • Varenicline

43. ARRANGE Referral to community resources (one-on-one counseling, regular group cessation programs, peer-to-peer programs) Exercise programs Automated follow-up support Smoker’s Quit Lines

44. Case Example: Smoking Cessation at CMHA Ottawa

45. REFERRAL GUIDELINES for CMHA Ottawa • Clients must have a serious mental illness, as defined by the Ministry of Health (Diagnosis, Disability, Duration) • Clients must be homeless or at imminent risk of becoming homeless. This means that the person is living in unstable housing, is engaging in behaviour that puts their housing at risk and/or where an eviction order could be served. • Clients with multiple and complex needs and as a result are not able to formulate and/or implement their own community support plan without intensive support will be priorized

49. Years in Service CMHA Service Recipients January to December 2008 n=908 10 + 3% 9 0.1% 8 2% 7 1% 6 2% 5 2% Number of Years 2% 4 3 8% 15% 2 1 23% 41% 0

50. High A D D I C T I O N Low Low High MENTAL ILLNESS