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Intervention Strategies for Tobacco and Behavioral HealthSteven A. Schroeder, MDMay 19, 2014

Presentation courtesy of The Smoking Cessation Leadership Center and Rx for Change1Conflict of Interest?

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3Smoking Prevalence by MH Diagnosis2007 NHIS dataSchizophrenia 59.1%Bipolar disorder46.4%ADD/ADHD37.2%

Current smoking: 1 MH31.9%2 MH41.8%3+ MH61.4%

Grant et al., 2004, Lasser et al., 2000Major depression 45-50%Bipolar disorder 50-70%Schizophrenia 70-90%

Institutionalized vs. non 4Smoking Prevalence and Average Number of Cigarettes Smoked per Day per Current Smoker 1965-2010*

* Schroeder, JAMA 2012; 308:1586

Percent/Number of Cigarettes Smoked Daily5Myths 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 cant 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, 20116WHY HELP MENTAL HEALTH CONSUMERS QUIT?Improve health and overall quality of lifeIncrease healthy years of lifeImprove the effect of medications for mental health problemsDecrease social isolationHelp save money by not buying cigarettes Quitting smoking helps recovery 1234567As we conclude this section, there are many reasons why we, and others, need to help mental health consumers quit smoking. There are health, financial, social, and psychological benefits to quitting including: 1. Improve health and overall quality of life2. Increase healthy years of life3. Improve the effect of medications for mental health problems4. Increase social support for quitting5. Help to save money by not buying cigarettes6. Quitting smoking is a right and is important for recovery

Quitting smoking is an important right. Everyone deserves the right to live a tobacco-free life. It is important to be healthy to achieve a meaningful life.

Covered Benefits under ACA*4 counseling sessions of at least 10 each (including telephone, group &/or individualAll FDA approved tobacco cessation medications, including both RX and OTCOffered at least twice yearlyNo prior authorization required.No co-pays, co-insurance, or deductibles

* 20148System Elements for Cessation Programs*Identification of smokersTraining (clinicians and other staff)Dedicated staff for cessationInclude cessation effort in staff evaluationPromote hospital and clinic policies

* AHRQ9Lessons Learned at SCLCIdentify and support local championsNeed to identify smoking status (EHR)Involve and train office/hospital staffMeasure intervention frequency and give feedbackInclude in consumer satisfaction surveysHelp staff to quit (key for BH settings)Policies for smoke-free environmentsPeer support and counseling

102013 Common Strategy Groups for 8 SAMHSA Academy StatesQuitline referralsData DevelopmentCommunicationProvider EducationNC is a leaderOverall the average number of strategy groups decreased; Arkansas and North Carolina consolidated strategy groups to streamline the process of communicating among groups with overlapping interests. However, 3 main groups were consistent in all 7 states in 2013Quitlines, Data Development and Communicaton. 11Los Angeles County CPPW* PioneersSCLC worked with LA County on its CPPW grantCommunity-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 changeSCLC held specialized webinars, monthly phone calls, created custom toolkit, and conducted site visits to provide support and resources to the LA PioneersPioneers provided cessation services to clients and staff * Communities putting prevention to work12CPPW = Communities Putting Prevention to WorkLos Angeles County CTG* ChampionsSCLC is currently working with LA County on CTGSimilar to the CPPW project, but this grant is focused solely on behavioral health (BH) organizations providing both inpatient and outpatient servicesLA 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 campusAgain, 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 grant13CTG = Community Transformation GrantThe National Quitline Card

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15Online Smoking Cessation AssistanceOnline smoking cessation services now available for smokers who prefer using computers over telephonesAnonymity is a plus, as with telephone quitlinesEarly studies show promising efficacywww.quitnet.comwww.smokefree.govwww.becomeanex.org

www.becomeanex.org For patients who prefer computers to telephones, there are online services16Tips for Your OfficeReferral 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 illness17Top 10 SCLC Milestones, 2003-2013Helping incorporate smoking cessation into mainstream treatment of CMI and SA disordersProductive partnerships with health professional societies to promote SCAsk, Advise, Refer as acceptable SC strategy, and marketing 1-800-QUITNOW

18Top SCLC Milestones (2)Marketing Rx for change curriculumSCLC educational offeringsCollaborative work with SAMHSAPlace-based initiativesHelping Pfizer with a $4.5m SC grants program (39 grantees)Amplifying voices of cessation championsMultiple articles in scientific literature19Knowledge Gaps Re Smoking CessationMost studies supported by pharmaImportant populations omitted by pharma:--behavioral health --light and intermittent smokers--incarcerated persons--youth--pregnant women20Cessation Knowledge Gaps (2)Optimal length of cessation drug treatment (FDA says 12 weeks)Natural history of quit attemptsMenthol!Epidemiology of quitline outreach Gender and ethnic differences no data so far that approach should vary21The Electronic Cigarette *Aerosolizes nicotine in propylene glycol Cartridges contain about 20 mg nicotineSafety unproven, but >cigarette smokeBridge use or starter product?Probably deliver < nicotine than promisedNot approved by FDAMy advice: avoid unless patient insists* Cobb & Abrams. NEJM July 21, 2011; Fiore, Schroeder, Baker, NEJM Jan 23, 201422Smoking Profile, 2014Most clinicians and policy makers live in a non-smoking gated communitySmoking now marginalized to the poor and the disadvantaged, plus some young immortalsThus tobacco control=social justice issueTobacco industry fights domestic rear guard action while expanding overseas23Q and A24SCLC Top 10 Wish List (Emerging Directions) 2014--Continued work with BH professionals, including military and Dept. of DefenseContinued work with targeted health professionalsExtend the reach of quitlinesBan cigarette sales from pharmacies (!!!)Reduce tobacco use by college studentsInclude SC in AA and other 12 step programs25SCLC Top Ten Wish List (2)Expand work with HRSAFurther adoption of Joint Commission/NQF tobacco core measuresAddress tobacco use among low SES and disabled persons in low income housingCriminal justice involved populations

26A Tale of Two CancersLung vs. BreastMany more deaths from lung cancer for both genders, but even just for womenYet more attention, including NIH research $, devoted to breast cancer; no race for the cure or brown ribbonReasons--different advocacy levels (stigma)--lack of public spokeswoman--fewer lung cancer survivors27Reasons for Not Helping Patients Quit1. Too busy2. Lack of expertise3. No financial incentive4. Lack of available treatments and/or coverage5. Most smokers cant/wont quit6. Stigmatizing smokers7. Respect for privacy8. Negative message might scare away patients9. I smoke myself10.Electronic medical record system problems (EPIC)28Medications Affected by SmokingBrand Name Generic NameElavilAmitriptylineAnafranilClomipramineAventyl/PamelorNortiptylineTofranilImipramineLuvoxFluvoxamineThorazineChlorpromazineProlixinFluphenazineHaldolHaloperidolClorizarilClozapineZyprexaOlanzapineTylenolAcetominophenInderalPropanololSlo-bid, Slo-Phyllin,TheophyllineTheo-24, Theo-Dur,Theobid, TheoventCaffeine

29Financial ImpactPeople 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

*Steinberg, 200430