Intervention Strategies for
Tobacco and Behavioral
Health
Steven A. Schroeder, MD
May 19, 2014
Presentation courtesy of
The Smoking Cessation Leadership Center
and Rx for Change
Conflict of Interest?
Smoking Prevalence by MH Diagnosis
2007 NHIS data
 Schizophrenia
 Bipolar disorder
 ADD/ADHD
59.1%
46.4%
37.2%
Current smoking:
 1 MH
 2 MH
 3+ MH
31.9%
41.8%
61.4%
Grant et al., 2004, Lasser et al., 2000



Major depression
Bipolar disorder
Schizophrenia
45-50%
50-70%
70-90%
Percent/Number of Cigarettes Smoked Daily
Smoking Prevalence and Average
Number of Cigarettes Smoked per Day
per Current Smoker 1965-2010*
* Schroeder, JAMA 2012; 308:1586
Myths 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 can’t 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, 2011
WHY HELP MENTAL HEALTH
CONSUMERS QUIT?
1 Improve health and overall quality of life
2 Increase healthy years of life
Improve the effect of medications for mental health
3 problems
4 Decrease social isolation
5 Help save money by not buying cigarettes
6 Quitting smoking helps recovery
Covered Benefits under ACA*
4 counseling sessions of at least 10’ each
(including telephone, group &/or individual
 All FDA approved tobacco cessation
medications, including both RX and OTC
 Offered at least twice yearly
 No prior authorization required.
 No co-pays, co-insurance, or deductibles

* 2014
System Elements for Cessation
Programs*
Identification of smokers
 Training (clinicians and other staff)
 Dedicated staff for cessation
 Include cessation effort in staff evaluation
 Promote hospital and clinic policies

* AHRQ
Lessons Learned at SCLC
Identify and support local champions
 Need to identify smoking status (EHR)
 Involve and train office/hospital staff
 Measure intervention frequency and give
feedback
 Include in consumer satisfaction surveys
 Help staff to quit (key for BH settings)
 Policies for smoke-free environments
 Peer support and counseling

2013 Common Strategy Groups
for 8 SAMHSA Academy States
Quitline referrals
 Data Development
 Communication
 Provider Education

– NC is a leader
Los Angeles County CPPW*
Pioneers
SCLC worked with LA County on its CPPW grant

Community-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 change

SCLC held specialized webinars, monthly phone calls,
created custom toolkit, and conducted site visits to
provide support and resources to the LA Pioneers

Pioneers provided cessation services to clients and staff
* Communities putting prevention to work
Los Angeles County CTG*
Champions
SCLC is currently working with LA County on CTG

Similar to the CPPW project, but this grant is focused
solely on behavioral health (BH) organizations providing
both inpatient and outpatient services

LA CTG champions were tasked with making policy

Again, SCLC held specialized webinars, monthly phone
calls, created custom toolkit, and conducted site visits to
provide support and resources to the LA champions
changes and implementing tobacco cessation protocols
(for both clients and staff) as part of plan to become a
smoke free campus
* Community transformation grant
The National Quitline Card
—
60
50
40
30
20
10
0
48.9
36.9
27.8
16.1
A
ny
5.2
A
lc
oh
ol
D
ru
g/
re
ni
a
zo
ph
ol
ar
(Zhu,et al, 2009. Unpublished data)
Sc
hi
B
ip
D
ep
re
ss
i
A
nx
ie
ty
7.1
on
% Smoking
Self-Reported Mental Health
Issues Among Helpline Callers
Online Smoking Cessation
Assistance
Online smoking cessation
services now available for
smokers who prefer using
computers over telephones
 Anonymity is a plus, as
with telephone quitlines
 Early studies show
promising efficacy

– www.quitnet.com
– www.smokefree.gov
– www.becomeanex.org
www.becomeanex.org
Tips for Your Office
Referral forms to the quitline (1-800QUITNOW)
 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 illness

Top 10 SCLC Milestones, 20032013
Helping incorporate smoking cessation
into mainstream treatment of CMI and SA
disorders
 Productive partnerships with health
professional societies to promote SC
 Ask, Advise, Refer as acceptable SC
strategy, and marketing 1-800-QUITNOW

Top SCLC Milestones (2)
Marketing Rx for change curriculum
 SCLC educational offerings
 Collaborative work with SAMHSA
 Place-based initiatives
 Helping Pfizer with a $4.5m SC grants
program (39 grantees)
 Amplifying voices of cessation champions
 Multiple articles in scientific literature

Knowledge Gaps Re Smoking
Cessation
Most studies supported by pharma
 Important populations omitted by pharma:
--behavioral health
--light and intermittent smokers
--incarcerated persons
--youth
--pregnant women

Cessation Knowledge Gaps (2)
Optimal length of cessation drug
treatment (FDA says 12 weeks)
 Natural history of quit attempts
 Menthol!
 Epidemiology of quitline outreach
 Gender and ethnic differences— no data
so far that approach should vary

The Electronic Cigarette *
Aerosolizes nicotine in propylene glycol
 Cartridges contain about 20 mg nicotine
 Safety unproven, but >cigarette smoke
 Bridge use or starter product?
 Probably deliver < nicotine than promised
 Not approved by FDA
 My advice: avoid unless patient insists

* Cobb & Abrams. NEJM July 21, 2011; Fiore, Schroeder, Baker, NEJM
Jan 23, 2014
Smoking Profile, 2014
Most clinicians and policy makers live in a
non-smoking “gated community”
 Smoking now marginalized to the poor
and the disadvantaged, plus some “young
immortals”
 Thus tobacco control=social justice issue
 Tobacco industry fights domestic rear
guard action while expanding overseas

Q and A
SCLC Top 10 Wish List
(Emerging Directions) 2014-Continued work with BH professionals,
including military and Dept. of Defense
 Continued work with targeted health
professionals
 Extend the reach of quitlines
 Ban cigarette sales from pharmacies (!!!)
 Reduce tobacco use by college students
 Include SC in AA and other 12 step
programs

SCLC Top Ten Wish List (2)
Expand work with HRSA
 Further adoption of Joint Commission/NQF
tobacco core measures
 Address tobacco use among low SES and
disabled persons in low income housing
 Criminal justice involved populations

A Tale of Two Cancers—Lung
vs. Breast
Many more deaths from lung cancer for
both genders, but even just for women
 Yet more attention, including NIH research
$, devoted to breast cancer; no race for
the cure or brown ribbon
 Reasons
--different advocacy levels (stigma)
--lack of public spokeswoman
--fewer lung cancer survivors

Reasons for Not Helping Patients Quit
1. Too busy
2. Lack of expertise
3. No financial incentive
4. Lack of available treatments and/or coverage
5. Most smokers can’t/won’t quit
6. Stigmatizing smokers
7. Respect for privacy
8. Negative message might scare away patients
9. I smoke myself
10.Electronic medical record system problems (EPIC)
Medications Affected by Smoking
Brand Name
Elavil
Anafranil
Aventyl/Pamelor
Tofranil
Luvox
Thorazine
Prolixin
Haldol
Clorizaril
Zyprexa
Tylenol
Inderal
Slo-bid, Slo-Phyllin,
Theo-24, Theo-Dur,
Theobid, Theovent
Generic Name
Amitriptyline
Clomipramine
Nortiptyline
Imipramine
Fluvoxamine
Chlorpromazine
Fluphenazine
Haloperidol
Clozapine
Olanzapine
Acetominophen
Propanolol
Theophylline
Caffeine
Financial Impact


People 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, 2004