INTEGRATING TOBACCO TREATMENT INTO ADDICTION

SERVICES

Mike DeVillaer

Provincial Services, CAMH

Department of Psychiatry & Behavioural Neurosciences, McMaster University

Addictions Ontario ConferenceMay 31 2011

Coordinating Team Mike DeVillaer, Provincial Services, CAMH Peter Selby, Addictions Program, CAMH Barney Savage, Public Policy, CAMH JF Crepault, Public Policy, CAMH Norma Medulun, Addictions Ontario Ian Stewart, Ontario Federation of Community

Mental Health and Addiction Programs

Survey Research Associate: Natalie MacLeod, CAMH

Project Partner: ConnexOntario

Funding

The CAN-ADAPTT Project Tobacco Control Programme Health Canada

Buy In ?

Economic Costs of Drug Problems in Ontario,

2002 = $14,300 millionIllicit Drugs

20.4%

Alcohol37.2%

Tobacco42.4%

Rhem et. al. (2006) The Costs of Substance Abuse in Canada in 2002. Canadian Centre on Substance Abuse.

1.3+ Million Alcohol-, Tobacco- & Illegal Drug-Related Hospital Days,

Ontario 2002

17.8% of all hospital days

58.8

33.1

8.10

20

40

60

80

Smoking Alcohol Illegal Drugs

%

Rehm J. et.al. (2006). The Costs of Substance Abuse in Canada, 2002. Canadian Centre on Substance Abuse.

Drug-related Deaths in Ontario (2002)

Drug-related19%

Other81%

Rehm J. et.al. (2006). The Costs of Substance Abuse in Canada, 2002. Canadian Centre on Substance Abuse.

All deaths = 82,234

Type of Drug-related Deaths in Ontario (2002)

Tobacco, 86.2%

Alcohol 9.1%

Illegal Drugs, 4.2%

Rehm J. et.al. (2006). The Costs of Substance Abuse in Canada, 2002. Canadian Centre on Substance Abuse.

Drug-related deaths = 15,253

From the General Population to the Addiction Treatment Population

more addiction treatment clients die from tobacco-related disease than from all other causes combined (Hurt et al.,1996)

The Provocative Question

Is Ontario’s addiction treatment system saving people from the perils of other drugs so they can die from their use of tobacco ?

Smoking Prevalence in Addiction Treatment

US median across all studies: 76.3% For any single year: Lowest: 65.0% Highest: 87.2% (J. Guydish, et. al., 2011)

Ontario DATIS (2009-10): 46.4%

High Demand

2009-10: 22,775 clients identified tobacco as a problem substance (DATIS, 2010)

third highest, behind alcohol and cannabis

Problem Drugs Identified by People in Drug Treatment Programs in Ontario, 2009-10

2.3

2.4

3.6

16.5

17.1

18.2

21.7

32.6

68.8

0 10 20 30 40 50 60 70 80

Heroin/Opium

Ecstacy

Benzodiazepines

Crack

Cocaine

Presc. Opioids

Tobacco

Cannabis

Alcohol

% of Clients

CAMH: DATIS Database May 2010; n =104,954

Our clients know that tobacco is harming them, and they are telling us so

It Makes a Difference Non-smoking clients in addiction treatment

programs have better outcomes than those who continue to smoke (McCarthy et. al., 2002; Satre et. al.,2007)

when we help our clients quit smoking we improve their overall health

may also improve their outcomes for other drug problems

Nova Scotia, Canada

Ministry of Health-funded addiction treatment programs are mandated to provide tobacco treatment to those clients who want it

Ontario Addiction Treatment Policy Arena

Ontario Ministry of Health’s “Setting The Course: A Framework for Integrating Addiction Treatment Services In Ontario” (1999) did not include the words ‘tobacco’ or ‘smoking’

2010: MH&LTC released Report of the Minister’s Advisory Group on the 10-Year Mental Health and Addictions Strategy

the words tobacco & smoking do not appear In contrast, alcohol has lots of mentions

Bottom Line

deaths hospitalization economic costs treatment outcomes health status

tobacco one of our biggest drug problems maybe the biggest

Why not recognized ?

not as much highly visible behavioural or social disruption

no personal crises requiring urgent attention

serious physical harm occurs later in life manifested in hidden settings of hospital

wards & home confinement

The Necessary Questions

Do you smoke tobacco ?

Would you like some help to quit ?

At minimum, a referral…

An Integration Issue

integrating addictions & mental health integrate treatment of all addictions ? major theme in the Ministry’s proposed 10

year strategy highlighted in letter of transmittal to the

Minister “We are recommending more integrated

services that will make better use of existing skills and resources.”

So what do we do about it ?

CAMH Tobacco Policy Group 2008

Workgroup comprised of representatives from: Addictions Ontario CAMH Ontario Federation of Community Mental Health

& Addiction Programs

ConnexOntario

Field Consultation, March 2009 Invitation sent to addiction providers in members of

Addictions Ontario & Ontario Federation of Community Mental Health and Addiction Programs

34 addiction service providers: front-line & mgt Purpose: identify, for clients, counsellors & programs, the

benefits, hurdles & solutions for integrating tobacco treatment

Participant feedback was very positive Full report sent to all member agencies of AO &

Federation & available at camh.net

Benefits for Clients

Improved health and quality of lifeConvenience of one program addressing all addiction issues

Quitting smoking reduces risk for relapse to other drug use

Clients

Hurdles SolutionsSmoking: cope with anger, fear, stress & loneliness

Nicotine replacement; identify alternate coping mechanisms

Smoking counsellors may provide triggers for clients

Ideally staff would be non-smokers; supported to quit

Contraband cigarettes are cheap

Explore clients’ finances; even cheap smokes aren’t that cheap

Clients more motivated to deal with crises in their lives

Benefits for Counsellors

Generic clinical knowledge & skills apply to tobacco treatmentNicotine replacement is a powerful tool they can useSmoking counsellors can quit; improve their own health

Counsellors

Hurdles SolutionsOver-worked, so unable to offer tobacco treatment groupsSome staff use cigarettes to reward client progress in treatment

Attitude shift important for clients & staff

Clients may not self-identify as nicotine addicts

Counsellors take the initiative to prompt

Benefits for Programs

Engagement in best practices for addictions treatmentNormalizes non-smoking; communicates a consistent professional health promotion message

Decreased relapse rate should shorten wait lists

Programs

Hurdles SolutionsCost of training staffCost of nicotine replacement products

Use budget surplus to stockpile NRT

Additional funding required Business case re: long-term health care savings

Perception that tobacco is not an addiction, so people can quit on their own

Education - TEACH

Adding a smoking cessation component requires a cultural shift at programs

Early adopters have some good advice for us

Survey the Field

Two Questions:

1) Provide tobacco treatment ? (yes/no)

2) If no, what are the barriers ?

Option: comments

Survey Distribution

email to members of AO & OFCMHAP 183 organizations operating 1395 programs emailed again 10 days later phone call to non-responders a week later all organizations were phoned 2 or 3 times CAMH’s Provincial Services followed up with

some non-respondents in their respective communities

Survey closed May 2010 Full & summary reports: camh.net

Results: Response Rate

1130 programs run by 132 organizations responded

81.0% of programs 72.1% of organizations

Results: Prevalence of Tobacco Treatment in Addiction Services

tobacco treatment provided by 266

programs operated by 31 organizations

23.5% of programs 23.5% of organizations

Results: Barriers Organized by 3 implementation strategies:

1) Increase Awareness (18.0 % of barriers)

not important to clients clients need smoking to cope with problems not as important as other issues jeopardize other treatment goals too dramatic of a change for program’s culture increase program wait times

Results: Barriers (cont’d)

2) Mandate Renewal (28.6 % of barriers) no formal mandate from funder

(MoH&LTC)

3) Resources (53.2% of barriers) staff training stop-smoking medication adequate staffing levels

So, where are we ?

Big problem No easy solution

Give up ?

“When I read about the evils of drinking, I gave up reading.”

Henny Youngman

Why Are Alcohol & Tobacco Our Biggest Problems?

legal aggressively & seductively marketed to

people not just allowed, but encouraged

Lifestyle Ads

2 ads 2 brands

2 types of men

2 market segments

Dakota: R.J. Reynolds Tobacco Company, 1990

marketing campaign for a new cigarette brand

targeted young, poorly educated, white women

"virile females" leaked to the

Washington Post

Details in Leaked Document

target: women with no education beyond high school women whose favourite pastimes included "cruising",

"partying", attending "Hot Rod shows", & "tractor pulls" with their boyfriends

favourite television roles are "evening soap opera bitches“

spend her free time "with her boyfriend doing whatever he is doing“

chief aspiration is "to get married in her early twenties"

Common Themes in Tobacco Advertising

1) athletics: athletic male wearing a basketball jersey and baseball cap

2) nicotine as appetite suppressant

a woman who might wish to lose some weight

large confection suggests dieting may not be working

"lights", low calorie food products

3) romance: 'sweetheart' suggests that there may be a romantic encounter looming

Market Uptake ?Tobacco Control, Summer 1998: prior to the start of the Joe Camel campaign, Camel’s

share of the youth market (ages 12-17) was less than 1%

year and a half later, it had risen to 8% by 1993, had climbed to 13%.

U.S. Centre for Disease Control, October, 1998: 73% increase in the number of American teens who

became daily smokers since the debut of the Joe Camel ad campaign in 1988

Marketing Memorandum, stamped "RJR Secret", 1997

"To ensure increased and longer term growth of Camel Filter, the brand must increase its share of penetration among the 14-24 age group which have a new set of liberal values and which represent tomorrow's cigarette business."

But publicly…

R.J. Reynolds 1994 statement:

“…that smoking is a choice for adults and that marketing programs are directed at those above the age to smoke."

Markets & Clients

Just as a market has segments – So does the population of tobacco smokers They are not all the same Many of those who continue to smoke may be

very different from those who have quit

Public Health Tobacco Strategy

The strategies that have brought us unprecedented declines in smoking rates may not be the same strategies that will appeal to those who continue to smoke

We will need new strategies

Tobacco Industry

What strategies do we use to make sure that current smokers do not join the majority of non-smokers ?

As before, they will focus on the vulnerable – your clients

3-4 x more likely to smoke than the general population

Tobacco Industry & Vulnerable Market Segments

not social needs but personal psychological needs:

stress relief behavioral arousal performance enhancement obesity reduction

(Le Cook et. al, 2003)

We need your help …

… to protect your clientsfrom the tobacco industry

Progress, Setbacks

&Next Steps

Progress: Modest but Encouraging

programs providing tobacco treatment are now identified as such in DART database

Connex staff can search their database client search on DART website coming

Connex provides annual updates to reflect progress

One Year Later:Are more programs integrating tobacco ?

Survey Baseline (May 2010): 23.5%

ConnexOntario Update (May 2011) Programs: 23.9% Organizations: 24.2%

barriers are very real

What are we doing about the barriers identified in our survey ?

Increase Awareness

Making Gains Two CAMH in the Community events National tobacco conferences McMaster research day AO Conference

Mandate Renewal

Communication strategy being developed:

LHINs Ministry

Needed Resources

Funding proposal being prepared for Ministry:

increased awareness (OTN session) meeting of addiction treatment organizations

currently providing tobacco treatment training in tobacco treatment (TEACH) support for community of practice access to stop-smoking medications improved staffing capacity

System transformation

takes a

long time …

But…

Read our reports:www.camh.net/Public_policy/index.html

Additional information:michael_devillaer@camh.net