Increasing Access to Tobacco Cessation Services for People in Mental Health – The Time is Now

1. Increasing Access to Tobacco Cessation Services for People in Mental Health – The Time is Now Smoking Cessation Leadership Center Access 2008: Building a Tobacco-Free Future March 26, 2008

2. The Smoking Cessation Leadership Center • Began in 2003 as a Robert Wood Johnson National Program Office with a $10-million, five-year grant • Aimed at helping clinicians do a better job intervening with tobacco users • Additional funding from VA, American Legacy Foundation • New foray into behavioral health arena, from Legacy grant

3. SCLC’s Aim • We want more people who want to quit smoking to get the help and support they need to succeed • Access to cessation tools and resources needs to be widened for all groups • Health care providers have a special role, as the many partners we have already enlisted will attest • Examples: nurses, dental hygienists, physicians, respiratory therapists, physician assistants, pharmacists, peer specialists

4. What Has Been Our Strategy? • Make cessation intervention simpler, more concrete and easier to do, as embodied in Ask Advise Refer and the wallet card • Work as members of nonhierarchical, results-driven, data-supported partnerships • Spread the word through the channels of our partners and through our own connections

5. Our Partners • Ten formal partnerships with professional organizations or groups of organizations • Family physicians, physician assistants, emergency physicians, anesthesiologists, respiratory therapists, dental hygienists, nurses, pharmacists • including National Mental Health Partnership for Wellness and Smoking Cessation • Five institutional/other projects • JCAHO, Kaiser, VA, Make It Your Business/Step Up!, “It’s Quitting Time, LA”, Chicago Second Wind Smoking Cessation Initiative, “Washington Quits!”

6. One Example -- The American Dental Hygienists Association (ADHA) Smoking Cessation Initiative • Baseline and Target • Baseline 25% in 2001 Journal of Dental Hygiene study (Winter 2001) • Increase to 50 the percentage of dental hygienists that screen their clients regarding tobacco use (rate, type and amount) by 2006.

7. Ask. Advise. Refer. = 5 A’s Ask Ask. Every patient/client about tobacco use. Advise Assess Assist Advise. Every tobacco user to quit. Arrange Refer. Determine willingness to quit. Provide information on quitlines. Refer to Quitlines ADHA Smoking Cessation Initiative (SCI)

9. National Survey Results • 56% of dental hygienists offer cessation treatment at every or most visits • 71% intervene with “higher risk clients” • 78% of those respondents who had accessed the AAR website had incorporated cessation information into practice

10. American Academy of Family Physicians • 390,000 cards distributed

11. American Society of Anesthesiologists 2007 Pilot Study 8 of 14 sites % Anesthesiologists referring smokers pre-op to quitlines

12. Why Our Focus on Mental Health? • Prevalence is 75 percent for those with either addictions and/or mental illness, as opposed to 20.9 percent for the general population • In mental health settings, about 30-35 percent of the staff smoke

13. People reporting a mental disorder in the past month consumed approximately 44.3% of all cigarettes smoked in the U.S. Lasser, Karen; Boyd, J. Wesley; Woolhandler, Steffie; Himmelstein, David U.; McCormick, Danny; Bor, David H., "Smoking and mental illness: A population-based prevalence study." JAMA, The Journal of the American Medical Association. Nov 22-29, 2000, 284, (20), 2606 - 2610.

14. Rates of smoking are 2-4 times higher among people with psychiatricdisorders and substance use disorders. Kalman D, Morissette SB, George TP. American Journal on Addictions. 2005, 106-123.

15. Smoking Prevalence among People with Mental Illnesses: Major depression 50 to 60 % Anxiety disorder 45 to 60 % Bipolar disorder 55 to 70 % Schizophrenia 65 to 85 % * 20% of those with schizophrenia started smoking at college age and many began smoking in mental health settings receiving cigarettes for good behavior. Presentation at the NASMHPD Medical Directors Council Technical Report Meeting on Smoking Policy and Treatment at State Operated Psychiatric Hospitals, April 20-21, 2006, San Francisco, California. * DeLeon et al., in press.

16. 30%-35% of Mental Health Providers Smoke Rates of smoking among treatment staff in mental health and substance abuse facilities and programs are higher than other health care professionals: NASMHPD Research Institute, Inc. (2006). Survey on Smoking Policies and Practices for Psychiatric Facilities. *** Strouse R, Hall J and Kovac M. Survey of Health Professionals' Knowledge, Attitudes, Beliefs, and Behaviors Regarding Smoking Cessation Assistance and Counseling. Princeton, N.J.: Mathematica Policy Research, Inc., 2004, 1-16. Primary Care Physicians 1.7 %Emergency Physicians 5.7 %Psychiatrists 3.2 % Registered Nurses 13.1 % Dentists 5.8 % Dental Hygienists 5.4 % Pharmacists 4.5 % ***

17. 41% of state psychiatric facilities are smoke-free NASMHPD Research Institute, Inc. (2006). Survey on Smoking Policies and Practices for Psychiatric Facilities. Presented by Joe Parks, M.D. at the NASMHPD Medical Directors Council Technical Report Meeting on Smoking Policy and Treatment at State Operated Psychiatric Hospitals.

18. A Targeted Population • As smoking prevalence declines, a greater proportion of smokers are in this population • Tobacco companies actively target the mentally ill and substance abusers • This is proven through tobacco papers (Project SCUM)

19. * Also suffer frommental illness and/or substance abuse Behavioral Causes of Annual Deaths in the United States, 2000 435 Number of deaths (thousands) * * 112 Sexual Alcohol Motor Guns Drug Obesity/ Smoking Behavior Vehicle Induced Inactivity Source: Mokdad et al, JAMA 2004;291:1238-1245 Mokdad et al; JAMA. 2005; 293:293 Flegal KM, Graubard BI, Williamson DF, Gail, MH. Excess deaths associated with underweight, overweight, and obesity. JAMA 2005;293:1861-1867

20. Another Eye-Opening Study • New NASMHPD study Morbidity and Mortality in People with Serious Mental Illness, showed 25-year gap in life expectancy

21. USA Today Front Page Thursday, May 3, 2007

22. History in Mental Health Outreach • Bob Glover, executive director of NASMHPD, asked Steve to present at the NASMHPD Directors Meeting (2004) in San Francisco • Interest among the MH community in doing something about tobacco was growing

23. A Fortuitous Referral • In 2005, RWJF sent us a query for funding from Joe Parks , NASMHPD, Medical Directors Council • Led to a grant to fund a meeting around making state psychiatric facilities smoke free • Summit convened 15 commissioners and state medical directors with NASMHPD in San Francisco (April 2006) and led to the Technical Report on Smoking Policy and Treatment in State Operated Psychiatric Facilities

26. The Legacy Grant • Legacy offered SCLC three years of funding largely to focus on mental health, as well as to expand our current efforts • Official project was launched in July 2006

27. Summit in Lansdowne • Held March 22-23, 2007 in Lansdowne, Va. • Brought together 24 partners including leading MH organizations such as NASMHPD, NAMI, MHA, etc. • Included cessation and quitline experts and SCLC staff

28. New Partnership was Born • The National Mental Health Partnership for Wellness and Smoking Cessation • 28 Partners • SCLC providing administrative support and a series of small grants to various MH participant organizations

29. American Legacy Foundation American Psychiatric Nurses Association American Psychiatric Association Association for Behavioral Health and Wellness Bazelon Center for Mental Health Law Behavioral Health Policy Collaborative California Smokers’ Helpline Campaign for Mental Health Reform Carter Center Mental Health Program Depression and Bipolar Support Alliance Mental Health America Mental Health Association of Southeastern PA National Alliance on Mental Illness National Association of County Behavioral Healthcare Directors National Association of Psychiatric Health Systems National Association of Social Workers National Association of State Mental Health Program Directors (NASMHPD) NASMHPD National Research Institute National Council of Community Behavioral Healthcare National Empowerment Center Ohio Department of Mental Health Robert Wood Johnson Foundation Substance Abuse and Mental Health Services Administration/Center for Mental Health Services Smoking Cessation Research and Policy Center at Oregon Health & Science University Smoking Cessation Leadership Center University of California San Francisco Department of Psychiatry University of Massachusetts Memorial Medical Center The Mental Health Partnership

30. Mission Statement “We the undersigned resolve to bring forth and lead a national partnership campaign to make health and wellness a priority for people with mental illnesses and for the providers who serve them. As a first and immediate focus, we commit ourselves to addressing the serious consequences of smoking and to emphasizing smoking cessation in all mental health service delivery settings.”

31. Action Plan • Promote consumer-driven education • Promote provider-motivated education • Promote staff wellness and smoking cessation • Outreach to key players and stakeholders • Build infrastructure • Assess and strengthen effectiveness of quitlines with consumers and staff • Develop data on smoking rates and behaviors

32. SCLC Grant Recipients • American Psychiatric Nurse Association • Depression and Bi-Polar Support Alliance • Mental Health America • National Association of State Mental Health Program Directors (NASMHPD) • NASMHPD, National Research Institute • National Council for Community Behavioral Healthcare • University of Colorado at Denver

33. Progress to date • Data is being collected • Concrete tools are being created • Presentations to draw awareness • Website is being created to house all resources • Partnership Communiqué

34. Data committee: NASMHPD, National Research Institute • Collect data on smoking cessation from Partnership constituent chapter organizations (MHA, NCCBH etc.) • Will capture first hand accounts of the smoking and non-smoking policies of state psychiatric facilities • Develop survey to address client care in relation to seclusion and restraint figures, aggression, and elopement, to name a few, and • Assess impact of employee smoking policy on staff activities.

35. Depression and Bi-Polar Support Alliance • Surveying membership to create smoking cessation tools for consumers • Developing curriculum and materials to teach certified peer specialists to become tobacco interventionists using Rx for Change: Ask-Advise-Refer • Finding an inroad to get Medicaid reimbursement for mental health professionals

36. NASMHPD • Developed technical assistance tool kit addressing how to implement smoking cessation in psychiatric hospital settings • Featured smoking cessation as a plenary topic during its recent National Summit of State Psychiatric Hospital Superintendents • Promoted 1-800-QUIT NOW

37. Assessment and Intervention Planning • Readiness to Quit and Stages of Change • Cultural Considerations • Smoking and Psychiatric Illness: Nicotine Effects and Other Considerations • Smoking Cessation Treatment for Persons with Mental Illnesses • Behavioral Interventions for Smoking Cessation • Prescribing Cessation Medications • Relapse Prevention • Local and National Tobacco Cessation Resources • Toolkit References • Literature Review

39. National Council for Community Behavioral Healthcare • Held a workshop on smoking cessation at its national conference • Surveying members to identify baselines and gaps in provider knowledge, in partnership with NRI

40. BEA Resource Guide • Bringing Everyone Along Resource guide was developed by the Tobacco Cessation Leadership Network, is now available to download from the TCLN website at www.tcln.org. • Compilation of the existing evidence base, professional experience and advice, and emerging resources • Developed to assist a diverse array of health professionals to tailor tobacco cessation services to meet the unique needs of tobacco users with mental health or substance abuse disorders

41. American Psychiatric Nurses Association • Summit held Feb. 14-16, 2008 • 15 leaders in psychiatric nursing • Baseline is • 61% of Psych Nurses do brief interventions (AAR ) • 29% of Psych Nurses do intensive (5A’s) • Target is to increase both categories by 5% each year • Action plan: • Raise awareness • Partner with States • Establish an education forum and media campaign

42. Resources • Quarterly Newsletter • Brochures, Handouts • Tobacco Treatment Resource Directory • CE training for MH providers-UMDNJ-Robert Wood Johnson Medical School • Articles and Publications • www.njchoices.org

43. Other Partners Also Stepping Up • National Association of Psychiatric Health Systems • Presentation to about two hundred NAPHS administrators on smoking cessation via conference call in July 2007

44. National Mental Health Consumer Self-HelpClearinghouse • Devoted the lead story in its recent newsletter to smoking cessation.

45. Momentum in Other Avenues • Presentations in: • National Conference on Tobacco or Health ‘07 • American College of Mental Health Administrators • National Alliance on Mental Illness • Society for Research on Nicotine and Tobacco • Society for Behavioral Medicine

46. The Partnership Communique • Originally designed to keep partners connected • Growing interest has expanded the list to all who are interested or have something to add • Submit updates to csaucedo@medicine.ucsf.edu

47. The Partnership Website Resources include presentations, publications, smokefree facilities toolkit, provider toolkit, partnership communiqué and awareness posters and video

48. Next Steps • Disseminating tools of best practices • Learning more about how quitlines can interface with the mental health population • Addressing issues for staff as well as consumers • Maintaining momentum • Adding partners

49. What can you do? • Use these resources • Refer your colleagues • Sign up for the MH Communiqué • Refer staff and patients to 1 800 Quit Now or local services