Substance Misuse Smoking Cessation Pilot:Implementation and Interim Findings

Dr Gordon Morse – Medical DirectorNeesha Chand – Special Projects Manager

The need…(thanks to Lynda Bauld)

Smoking and substance misuse (APMS, 2007)

Smoking and Substance Smoking and Substance MisuseMisuse

Smokers’ higher subjective Smokers’ higher subjective symptoms of methadone inadequacy symptoms of methadone inadequacy (Tacke et al, 2001)(Tacke et al, 2001)

Smoking impedes cognitive recovery Smoking impedes cognitive recovery after alcohol abstinence after alcohol abstinence (Kalman et al, (Kalman et al, 2010)2010)

Smokers require higher doses of Smokers require higher doses of some benzodiazepines/opiates some benzodiazepines/opiates (RCP, (RCP, 2013)2013)

Examples of health Examples of health impactsimpacts

Cohort study of Cohort study of 845845 substance misuse substance misuse patients in Minnesota, US:patients in Minnesota, US: 222222 died during study died during study 214214 with death certificates: 51% with death certificates: 51%

documented a tobacco-related cause of documented a tobacco-related cause of death, > than proportion from alcohol & death, > than proportion from alcohol & other drug-related causes other drug-related causes (Hurt et al, 1996) (Hurt et al, 1996)

Tobacco and alcohol use multiplies risk Tobacco and alcohol use multiplies risk of developing cancers of upper of developing cancers of upper respiratory & digestive tracts respiratory & digestive tracts (Pelucchi et al, (Pelucchi et al, 2007; Kalman et al, 2010; Baca & Yahne, 2009)2007; Kalman et al, 2010; Baca & Yahne, 2009)

Staff and client attitudesStaff and client attitudes Staff rated nicotine dependence treatment Staff rated nicotine dependence treatment

significantly significantly lessless important than treatment of other important than treatment of other substancessubstances

53%53% (n=88) staff thought addressing smoking (n=88) staff thought addressing smoking should be put off until late or after a client’s should be put off until late or after a client’s primary addiction treatment & only primary addiction treatment & only 29%29% (n=40) (n=40) thought it should be addressed early in treatmentthought it should be addressed early in treatment

By contrast, By contrast, nearly half nearly half of clients thought it should of clients thought it should be addressed early in treatmentbe addressed early in treatment

Average rating of staff confidence in supporting Average rating of staff confidence in supporting someone who wanted to give up (on a 10 point someone who wanted to give up (on a 10 point scale) was 7.0 but varied considerablyscale) was 7.0 but varied considerably

TreatmentTreatment Smoking cessation doesn’t impact negatively on

success of abstinence from other substances; may improve outcomes

Meta-analysis of 19 RCTs of smoking-cessation Meta-analysis of 19 RCTs of smoking-cessation interventions for people in substance misuse interventions for people in substance misuse treatment and in recovery showed concurrent treatment and in recovery showed concurrent treatment of smoking resulted in a 25% treatment of smoking resulted in a 25% increased likelihood of long-term abstinence from increased likelihood of long-term abstinence from alcohol and illicit drugs (Prochaska et al, 2004)alcohol and illicit drugs (Prochaska et al, 2004)

Khara & Okoli, 2011; Burling et al, 2001; Kalman et al, 2010; Baca & Yahne 2009; Khara & Okoli, 2011; Burling et al, 2001; Kalman et al, 2010; Baca & Yahne 2009; Williams & Ziedonis, 2004; Prochaska et al, 2004; Stapleton et al, 2009; Goulay et al, Williams & Ziedonis, 2004; Prochaska et al, 2004; Stapleton et al, 2009; Goulay et al, 1994; Moore & Budney, 2001; Prochaska et al, 2004; Stuyt, 1997; 1994; Moore & Budney, 2001; Prochaska et al, 2004; Stuyt, 1997; Weinberger & Sofuoglu 1997

TreatmentTreatment

Adverse Childhood Event (ACE) study - 1998

asked 26,000 consecutive adults coming through Kaiser Permanente’s Department of Preventive Medicine in San Diego, California if they would be interested in helping us understand how childhood events might affect adult health status. Seventy-one percent agreed (17,421) - mean age 57

ACE Scores:growing up in:a household where someone was in prison where the mother was treated violentlywith an alcoholic or a drug user where someone was chronically depressed, mentally ill, or suicidalwhere at least one biological parent was lost to the patient during childhood – regardless of causerecurrent physical abuserecurrent severe emotional abusecontact sexual abuse

An individual exposed to none of the categories had an ACE Score of 0; an An individual exposed to none of the categories had an ACE Score of 0; an individual exposed to any four had an ACE Score of 4, etc. individual exposed to any four had an ACE Score of 4, etc.

Illicit Drug use

Licit Drug use - tobacco

NICE recommendations include:

Identifying people who smoke and offering and arranging support

Implement a comprehensive smoke free policy that includes the grounds

Support for staff smokers Training for staff

Building on & sharing best practice

Turning Point, PHE, South London and Maudsley NHS Foundation Trust (SLAM)

National Centre for Smoking Cessation Training (NCSCT) 9 smoking cessation substance misuse service pilot sites Share learning from the pilot that with other providers

and commissioners considering introducing or expanding smoking cessation

Senior management steer Smoking Cessation Project Tiers

SC Project Group: Jan Hernen (Clinical Psychologist), Neesha Chand (Project Lead), Darren Woodward (Project Sponsor)SC Working Group: Area Operation Managers (sign up to deliver action plan per pilot site)Smoking Cessation Leads: (operationally develop and deliver local action plans)

Methodology 1. benchmark service user smoking prevalence2. benchmark workforce attitudes and behaviour 3. train & engage staff4. review smoking policies 5. design interventions (assessment and goal planning)6. record activity and outcomes7. evaluate the pilots

1. SU prevalence TP benchmarking data extracted from April 2014 to

February 2015 in the nine pilot areas for– SU smoking status (currently smoking, had previously

smoked and had never smoked)– Data completeness or missing smoking status

Comparative data to be extracted after one year to test and demonstrate pilot outcomes

2. Workforce attitudes & behaviourTeam quiz & anonymous staff survey key findings

Most staff are open to including brief advice on smoking cessation and signposting into treatment as part of their interventionsMost staff already feel confident that they have the skills to support smokers to stopThere is a high level of staff receptiveness to the idea of cessation

3. Train & engage staff – consider timeline for launch

4. Review smoking policies Service user and local service protocols – SUI Peer mentor and volunteer local protocols Staff – manager guidance documents – including

breaks, e-cigarettes / vaping Staff wellbeing policies – improve direct access

“Staff working in substance misuse services are about twice as likely to smoke as the general population. The desire by two thirds of them to stop is a good indication of a need for substance misuse services to put on ‘stop smoking’ services for their own staff.” Don Lavoie, PHE

5. Design interventions Develop in conjunction with staff Consider how it will be recorded and monitored Keep changes minimal – essential questions only for

behaviour change and outcome measurements Changes made to core TP paperwork

– TP Assessment – NTA Goal Planner

Prompts – Assessment

Prompts – Recovery Planning

6. Data recording All activity & outcomes recorded on CIM (Client

Information Management) System – inconsistent Activity

– Smoking Assessment– Interventions (VBA & specialist level 2/NRT)– Referrals (specialist level 2/NRT)

Outcomes – Outcome section in CIM– 'Successful - No Longer Smoking‘ (new field)

7. Interim findings Activity has increased but recording is inconsistent Where commissioned KPI’s in place uptake is higher Mandatory fields would help with compliance – internal

exception reporting required (TOPS) Working groups and management steer is essential September 2015 – pilot evaluation will include Comparative data (Apr to Aug) improvements in

identification and interventions Sampling – assess impact of smoking cessation on

substance misuse treatment outcomes

Pilot outcome

Integrated smoking cessation & substance misuse provision…

Improved access to smoking cessation for service users AND staff

Interventions being delivering internally and signposted to externally