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 59.1% Schizophrenia 59.1% Bipolar disorder46.4% Bipolar disorder46.4% ADD/ADHD37.2% ADD/ADHD37.2% Current smoking: 1 MH31.9% 1 MH31.9% 2 MH41.8% 2 MH41.8% 3+ MH61.4% 3+ MH61.4% Grant et al., 2004, Lasser et al., 2000 Major depression 45-50% Major depression 45-50% Bipolar disorder 50-70% Bipolar disorder 50-70% Schizophrenia 70-90% Schizophrenia 70-90%

Smoking Prevalence and Average Number of Cigarettes Smoked per Day per Current Smoker * * Schroeder, JAMA 2012; 308:1586 Percent/Number of Cigarettes Smoked Daily

Myths About Smoking and Mental Illness* Tobacco is necessary self-medication (industry has supported this myth) Tobacco is necessary self-medication (industry has supported this myth) They are not interested in quitting (same % wish to quit as general population) 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) 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) 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) 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

Covered Benefits under ACA* 4 counseling sessions of at least 10’ each (including telephone, group &/or individual 4 counseling sessions of at least 10’ each (including telephone, group &/or individual All FDA approved tobacco cessation medications, including both RX and OTC All FDA approved tobacco cessation medications, including both RX and OTC Offered at least twice yearly Offered at least twice yearly No prior authorization required. No prior authorization required. No co-pays, co-insurance, or deductibles No co-pays, co-insurance, or deductibles * 2014

System Elements for Cessation Programs* Identification of smokers Identification of smokers Training (clinicians and other staff) Training (clinicians and other staff) Dedicated staff for cessation Dedicated staff for cessation Include cessation effort in staff evaluation Include cessation effort in staff evaluation Promote hospital and clinic policies Promote hospital and clinic policies * AHRQ

Lessons Learned at SCLC Identify and support local champions Identify and support local champions Need to identify smoking status (EHR) Need to identify smoking status (EHR) Involve and train office/hospital staff Involve and train office/hospital staff Measure intervention frequency and give feedback Measure intervention frequency and give feedback Include in consumer satisfaction surveys Include in consumer satisfaction surveys Help staff to quit (key for BH settings) Help staff to quit (key for BH settings) Policies for smoke-free environments Policies for smoke-free environments Peer support and counseling Peer support and counseling

2013 Common Strategy Groups for 8 SAMHSA Academy States Quitline referrals Quitline referrals Data Development Data Development Communication Communication Provider Education 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 —

Online Smoking Cessation Assistance Online smoking cessation services now available for smokers who prefer using computers over telephones Online smoking cessation services now available for smokers who prefer using computers over telephones Anonymity is a plus, as with telephone quitlines Anonymity is a plus, as with telephone quitlines Early studies show promising efficacy Early studies show promising efficacy – – –

Tips for Your Office Referral forms to the quitline ( QUITNOW) Referral forms to the quitline ( QUITNOW) Carbon monoxide breathalyzer (cost about $500 plus disposal mouthpieces) Carbon monoxide breathalyzer (cost about $500 plus disposal mouthpieces) One key question to ask: “When do you have your first cigarette of the day?” One key question to ask: “When do you have your first cigarette of the day?” Approach smoking as a chronic illness Approach smoking as a chronic illness

Top 10 SCLC Milestones, Helping incorporate smoking cessation into mainstream treatment of CMI and SA disorders Helping incorporate smoking cessation into mainstream treatment of CMI and SA disorders Productive partnerships with health professional societies to promote SC Productive partnerships with health professional societies to promote SC Ask, Advise, Refer as acceptable SC strategy, and marketing QUITNOW Ask, Advise, Refer as acceptable SC strategy, and marketing QUITNOW

Top SCLC Milestones (2) Marketing Rx for change curriculum Marketing Rx for change curriculum SCLC educational offerings SCLC educational offerings Collaborative work with SAMHSA Collaborative work with SAMHSA Place-based initiatives Place-based initiatives Helping Pfizer with a $4.5m SC grants program (39 grantees) Helping Pfizer with a $4.5m SC grants program (39 grantees) Amplifying voices of cessation champions Amplifying voices of cessation champions Multiple articles in scientific literature Multiple articles in scientific literature

Knowledge Gaps Re Smoking Cessation Most studies supported by pharma Most studies supported by pharma Important populations omitted 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) Optimal length of cessation drug treatment (FDA says 12 weeks) Natural history of quit attempts Natural history of quit attempts Menthol! Menthol! Epidemiology of quitline outreach Epidemiology of quitline outreach Gender and ethnic differences— no data so far that approach should vary Gender and ethnic differences— no data so far that approach should vary

The Electronic Cigarette * Aerosolizes nicotine in propylene glycol Aerosolizes nicotine in propylene glycol Cartridges contain about 20 mg nicotine Cartridges contain about 20 mg nicotine Safety unproven, but >cigarette smoke Safety unproven, but >cigarette smoke Bridge use or starter product? Bridge use or starter product? Probably deliver < nicotine than promised Probably deliver < nicotine than promised Not approved by FDA Not approved by FDA My advice: avoid unless patient insists 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” 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” Smoking now marginalized to the poor and the disadvantaged, plus some “young immortals” Thus tobacco control=social justice issue Thus tobacco control=social justice issue Tobacco industry fights domestic rear guard action while expanding overseas Tobacco industry fights domestic rear guard action while expanding overseas

Q and A

SCLC Top 10 Wish List (Emerging Directions) Continued work with BH professionals, including military and Dept. of Defense Continued work with BH professionals, including military and Dept. of Defense Continued work with targeted health professionals Continued work with targeted health professionals Extend the reach of quitlines Extend the reach of quitlines Ban cigarette sales from pharmacies (!!!) Ban cigarette sales from pharmacies (!!!) Reduce tobacco use by college students Reduce tobacco use by college students Include SC in AA and other 12 step programs Include SC in AA and other 12 step programs

SCLC Top Ten Wish List (2) Expand work with HRSA Expand work with HRSA Further adoption of Joint Commission/NQF tobacco core measures Further adoption of Joint Commission/NQF tobacco core measures Address tobacco use among low SES and disabled persons in low income housing Address tobacco use among low SES and disabled persons in low income housing Criminal justice involved populations 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 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 Yet more attention, including NIH research $, devoted to breast cancer; no race for the cure or brown ribbon Reasons 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 Generic Name ElavilAmitriptyline AnafranilClomipramine Aventyl/PamelorNortiptyline TofranilImipramine LuvoxFluvoxamine ThorazineChlorpromazine ProlixinFluphenazine HaldolHaloperidol ClorizarilClozapine ZyprexaOlanzapine TylenolAcetominophen InderalPropanolol Slo-bid, Slo-Phyllin,Theophylline Theo-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 $ per month $2, per year $23, per 10 years *Steinberg, 2004