1. Calling All Smokers and Their Loved Ones: Get Motivated and Quit NAMI Wisconsin Annual Conference Osthoff Resort, Elkhart Lake April 30, 2016 Bruce Christiansen, PhD Senior Scientist Center for Tobacco Research and Intervention UW School of Medicine and Public Health

2. Outline I. Background - why quit? II. Getting motivated (group activity) III. How to quit

3. I. Background Information There is a pressing need People who have a mental illness want to quit, can quit, and do quit Quitting delivers great benefit

4. There is a pressing need

6. STIGMA

7. There is a pressing need Additive mortality risks Heart disease is 7X higher than peers and more than 7x the suicide rate. Smoking influences development of metabolic syndrome in clients on antipsychotic drugs Average loss of life is 24 years

8. People with persistent mental illness want to quit, can quit, and do quit 31% ex-smokers

9. Why bother – the Benefits of Quitting A meta-analysis found that compared to those who did not quit, those that did experienced significant improvements in depression and anxiety and significant reductions in stress. The amount of reduction in anxiety and depression was equal to or bigger than what would have been expected from medications used to treat anxiety and depression. Taylor, McNeil, Girling, Farley, Linson-Hawley, Avegard “Change in Mental Health after Smoking Cessation: Systematic Review and Meta-analysis” BMJ 2014; 358:g1151

10. II. Getting Motivated

11. III. How to quit 1. What is the most common way of quitting?

12. III. How to quit 1. What is the most common way of quitting? The most common way of quitting is not the most effective way of quitting

13. III. How to quit 1. What is the most common way of quitting? 2. How effective is the best way of quitting?

14. III. How to quit 1. What is the most common way of quitting? 2. How effective is the best way of quitting? Smoking is a chronic disease. It may take multiple tries to quit successfully. Just because a method has not worked for you in the past doesn’t mean it won’t work for you in the future. Don’t get discouraged. Keep trying.

15. What is the most effective way to quit? Need to address the two key elements of addiction: Biology

16. 16

17. Biology 17

18. Biology 18

19. Biology Promotes release of another neurotransmitter in a different part of the brain - dopamine 19

20. Biology Biological dependence leads to withdrawal and cravings during cessation. 20

21. Biology 21 Do people keep smoking because it’s so pleasurable?

22. Biology 22 Do people keep smoking because it’s so pleasurable?

23. Biology 23 Over time, the only way to feel “normal” is to smoke. Smoking to drive withdrawal away leads some to conclude that smoking is relaxing.

24. Biology Withdrawal, and therefor, cravings, lasts a couple of weeks Consistent with this, the greatest risk for relapse is in the first couple of weeks – indeed the greatest risk for relapse is in the first couple of days post quit when the cravings are the strongest. But relapse does occur long after two weeks. Why? 24

25. What is the most effective way to quit? Need to address the two key elements of addiction: Biology Psychology

26. If the origins of physical addiction is biological, what is the origin of psychological addiction? 26

27. Psychology Behavior 27

28. Psychology Learning bonds – the A-B-Cs of behavior Antecedents (cues) Behavior Consequence (positive or negative) 28

29. Psychology Consequences of a high number of learning trials (cigarettes smoked)(repetition): Widespread urges Very strong learning bonds – resistance to extinction Automaticity Emotional connection “I’ve lost my best friend” 29

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31. 31 Brief digression on the nature of consequences: Why do people continue to smoke when the consequences are so dire?

33. Quitting the Hard Way Cold Turkey: Taking on both the biological and the psychological addiction at the same time. The smoker must contend with both the physiological addiction (withdrawal and cravings) but also the psychological dependence (urges) 33

34. A Better Way to Quit Guidance Support Medication 34

35. Medicines Seven FDA approved medications: Bupropion SR (Wellbutrin, Zyban) Nicotine Replacement Treatment (NRT) Nicotine Gum Nicotine Inhaler Nicotine Lozenge Nicotine Nasal Spray Nicotine Patch Varenicline (Chantix) 35

36. 36

37. How does Varenicline work? 37

38. How does Varenicline work? (Partial) Agonistic at the receptor sites (receptor sites are activated just like when nicotine is there so that withdrawal effects are reduced). (The brain thinks its getting nicotine.) (Partial) Antagonistic to nicotine so when a person smokes, there is no pleasure because all the receptor sites are already occupied so that smoking has no effect. 38

39. Why do medications work? Reduce, but do not eliminate, cravings Makes quitting easier, but not easy. Conceptually: allow the smoker to continue to receive nicotine (or as if nicotine was being received in the case of varenicline) so that cravings are less while the smoker begins to break the learning bonds that imprison him (Psychological dependence). 39

40. NRT: Nicotine patches Adapted from : Henningfield JE. Nicotine medications for smoking cessation. N Engl J Med 1995;333:1196-203 Patches provide a slow, consistent release of nicotine throughout the day Available in various shapes and sizes, Common side effects with patches include skin sensitivity and irritation 40

41. Guidance

42. Overall, breaking the A-B-C bonds What are the strongest bonds? How to get through an urge How to replace cigarettes What to do in tempting situations When to avoid situations (alcohol) vs when to address cravings Change self-talk How to keep motivation up Self-reward How to mobilize support

43. Guidance 43 Set a quit date: ideally within 2 - 3 weeks Tell others and ask for support: E.g., not to smoke around you Anticipate and plan for challenges and temptations: Plan how to overcome future challenges Challenges: stress, alcohol, other smokers, weight gain Coping plan: avoid alcohol and other smokers, stress healthy eating and an active lifestyle Remove all tobacco products - remove tobacco from home, car, and work environments Stress Abstinence: plan for total abstinence starting on the quit date, and stress sticking with treatment even if there is a slip or lapse

45. Wisconsin Tobacco Quit Line 45

46. What are Quit Lines? Free, confidential, tailored Available in every state May provide medication as well as counseling Staffed by highly trained, expert counselors One point of access: 1-800-QUIT-NOW (784- 8669) Can dramatically improve chances of successfully quitting smoking Recommended by the U.S. Public Health Services Clinical Practice Guideline for Treating Tobacco Dependence

47. Daily, 7 a.m. – 2 a.m. Translators in virtually every language Spanish language 877-2NO-FUME (266-3863)

48. How the Quit Line Works

49. Quit Coach Call 1-Call Program with a Quit Coach Registration Quit history Level of dependence Motivation in quitting Create Quit Plan Medications Unlimited enrollment Quit calls, 3 pillars of evidence-based treatment: Practical coaching/counseling for basic skills & problem solving Social support (direct provision and identification in social environment) Medication

50. NRT (Nicotine Replacement Therapy) 2-week starter kit of NRT Patch, gum, or lozenge 18 years old or older Health screening, use exclusions Direct mailed to caller’s home

51. Web Coach Provided in conjunction with phone coaching Participants can: Build their quit plans Track their progress “Talk” with Quit Coaches and other tobacco users in discussion forums Receive tailored coaching emails Unlimited access, 24/7 Video demonstration: http://www.ctri.wisc.edu/quitline_webcoach.html

52. Quit Kit

53. Other Quit Kit Support Materials “Enough Snuff”, a guide to quit smokeless tobacco “Butts Out”, for youth “Need Help Putting Out That Cigarette?”, for pregnant women “Usted puede dejar de fumar. Le ensenaremos como.”, for Spanish-speaking callers “Tips & Tools to Help You Quit Commercial Tobacco”, for Native American callers Fact Sheets Diabetes, Heart Disease, Asthma, COPD, Pregnancy, Secondhand Smoke

54. Information for Others

55. Referrals to local programs & services Callers offered referral to local quit-tobacco programs, where available Quit Coaches have made over 28,000 referrals since 2001 Another tool in the tool box; Offer as many resources to tobacco users as possible

56. Visit us at: www.WIQuitLine.org Quit Line Questions? Contact: Kate Kobinsky, MPH 608-265-5617 ks6@ctri.wisc.edu

58. www.ctri.wisc.edu 58

59. Questions