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