Intervention Strategies for Tobacco and

Behavioral Health

Steven A. Schroeder, MDMay 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 59.1% Bipolar disorder 46.4% ADD/ADHD 37.2%

Current smoking: 1 MH 31.9% 2 MH 41.8% 3+ MH 61.4%

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

Smoking Prevalence and Average Number of Cigarettes Smoked per

Day per Current Smoker 1965-2010*

* Schroeder, JAMA 2012; 308:1586

Per

cent

/Num

ber

of C

igar

ette

s S

mok

ed D

aily

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?

Improve health and overall quality of life

Increase healthy years of life

Improve the effect of medications for mental health problems

Decrease social isolation

Help save money by not buying cigarettes

Quitting smoking helps recovery

1

2

3

4

5

6

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 changes and implementing tobacco cessation protocols (for both clients and staff) as part of plan to become a smoke free campus

Again, 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 grant

The National Quitline Card

—

Self-Reported Mental Health Issues Among Helpline Callers

36.927.8

16.17.1 5.2

48.9

0

10

20

30

40

50

60

(Zhu,et al, 2009. Unpublished data)

% S

mo

kin

g

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 (1-800-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 illness

Top 10 SCLC Milestones, 2003-2013

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 busy2. Lack of expertise3. No financial incentive4. Lack of available treatments and/or coverage5. Most smokers can’t/won’t quit6. Stigmatizing smokers7. Respect for privacy8. Negative message might scare away patients9. I smoke myself10.Electronic medical record system problems

(EPIC)

Medications Affected by Smoking

Brand Name Generic NameElavil AmitriptylineAnafranil ClomipramineAventyl/Pamelor NortiptylineTofranil ImipramineLuvox FluvoxamineThorazine ChlorpromazineProlixin FluphenazineHaldol HaloperidolClorizaril ClozapineZyprexa OlanzapineTylenol AcetominophenInderal PropanololSlo-bid, Slo-Phyllin, TheophyllineTheo-24, Theo-Dur,Theobid, Theovent

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