1. Taking Charge: Understanding Tobacco Control’s Impact on Communities Christine Cheng, Partner Relations Director, Smoking Cessation Leadership Center Shelina D. Foderingham, Director Practice Improvement, The National Council Kansas Health Foundation, Fellows Program Friday, November 14, 2014 – Wichita, KS

2. © 2012 BHWP2 Today’s Topics Overview: National Landscape SCLC Partnerships: State and Local Community Tobacco Control: Leading Preventable Cause of Death Health Systems Changes Barriers and Myths Group Exercise

3. National Council for Behavioral Health

4. SAMHSA-HRSA CIHS, 2014 National Landscape

6. SAMHSA-HRSA CIHS, 2014

7. National Landscape

8. Cancer and Behavioral Health  More than 50% of people with terminal cancer have at least one psychiatric disorder.  Individuals with a mental illness may develop cancer at a 2.6 times higher due to late stage diagnosis because of inadequate screenings.  Individuals with a mental illness have a higher rate of fatality due to cancer.

9. SAMHSA-HRSA CIHS, 2014 What is the National Council doing?

10. Learning Collaborative and Communities – SUD, FQHC SAMHSA-HRSA Center for Integrated Health Solutions NY State Geriatric Technical Assistance Center Ohio Training & Technical Assistance Center CDC Capacity Building and National Behavioral Health Network for Tobacco & Cancer Control 10 Practice Improvement & Workforce Development

11. Jointly funded by CDC’s Office on Smoking & Health & Division of Cancer Prevention & Control Provides resources and tools to help organizations reduce tobacco use and cancer among people with mental illness and addictions 1 of 8 CDC National Networks to eliminate cancer and tobacco disparities in priority populations Free Access to… Toolkits, training opportunities, virtual communities and other resources Webinars & Presentations State Strategy Sessions #BHtheChange Visit www.BHtheChange.org and Join Today!www.BHtheChange.org

12. © 2012 BHWP12

13. © 2012 BHWP13 Smoking Cessation Leadership Center Began in 2003 as a Robert Wood Johnson Foundation National Program Office Subsequent grants from Legacy Foundation to address behavioral health, ARRA grant, CDC/CTG grants, SAMHSA for pioneers and state summits Aims to increase smoking cessation rates and increase the number of health professionals who help smokers quit.

14. © 2012 BHWP14 How We Work Identify champions Create partnerships Help create action plans Do not reinvent the wheel Low cost, no cost resources Promote message through health journals, publications and social media

15. © 2012 BHWP15 SCLC and Behavioral Health Convened leaders in BH for a summit in 2007 Meeting at SAMSHA with the then administrator Terry Cline in 2008, which lead to … SAMHSA 100 pioneers initiative in 2009 SAMHSA leadership academy for wellness and smoking cessation with 8 states from 2010-13 SAMHSA policy academy held in June 2014

16. © 2012 BHWP16 SAMHSA In-Service Training Poster July 7, 2008

17. © 2012 BHWP17 Grantees from all 3 SAMHSA centers: o CMHS, CSAT, CSAP Wide range of interventionists o Consumer groups o Health care providers o Community centers o Treatment centers o Youth o Rehabilitation centers 2 nd phase of initiative with 25 Pioneers 100 Pioneers for Smoking Cessation

18. © 2012 BHWP18 SAMHSA Pioneers Map Blue = Phase I Pioneers Yellow = Phase II Pioneers Represent 38 states

19. © 2012 BHWP19 Performance Partnership Model Used in all 8 SAMHSA leadership academy states Partnership organized around a specific, measurable result, asking 4 questions: 1.Where are we now? (baseline) % intervene with patient who smoke or current prevalence 2.Where do we want to be? (target) increase to % in xx years or decrease prevalence by xx% 3.How will we get there? (multiple strategies) 4.How will we know we are getting there? (evaluation/measures)

20. © 2012 BHWP20 Leadership Academies for Wellness and Smoking Cessation 2010-2013 Leadership Academies for Wellness and Smoking Cessation o Purpose: To launch statewide partnerships among behavioral health providers, consumers, public health groups, and other stakeholders to create and implement an action plan to reduce smoking prevalence among behavioral health consumers and staff. o Eight states selected to participate in 1-2 day planning summits

21. © 2012 BHWP21 8 State Leadership Academies 8

22. © 2012 BHWP22 Leadership Academy Participants State mental health department State substance abuse department State tobacco control department/state Medicaid department Consumer organizations Hospitals Federal agency representatives from SAMHSA, HRSA, CDC, VA Academic medical centers State branches of national advocacy groups such as NAMI or MHA Patient advocacy groups Community advocacy groups Youth organizations Insurance companies SCLC Leadership and staff Results-based facilitator

23. © 2012 BHWP23 2012 Progress Report: Common Strategy Groups Consumers and Community: 6 out of 7 states Provider Education: 6 out of 7 states Data Development: 5 out of 7 states State Level Policy: 5 out of 7 states Behavioral Health Facilities: 4 out of 7 states Quitline: 4 out of 7 states

24. © 2012 BHWP24 2013: Impact: Awareness of Tobacco Intervention among BH Providers 71% or 5 out of 7 states strongly agree

25. © 2012 BHWP25 State Leadership Academies Strongly Interested in Partnering with Others 100% or all 7 states strongly interested in partnering with other states

26. © 2012 BHWP26 Tobacco: Leading Preventable Cause of Death 1.How many annual deaths are caused by smoking? 1.What was the national prevalence in 1964 when the first Surgeon General’s report on smoking and health was released?

27. © 2012 BHWP27 Tobacco’s Deadly Toll 480,000 deaths in the U.S. each year 4.8 million deaths world wide each year 10 million deaths estimated by year 2030 50,000 deaths in the U.S. due to second-hand smoke exposure 8.6 million disabled from tobacco in the U.S. alone 46.6 million smokers in U.S. (78% daily smokers)

28. © 2012 BHWP28 Behavioral Causes of Annual Deaths in the United States Number of deaths (thousands) Mokdad et al, JAMA 2004; 291:1238-1245. Mokdad et al; JAMA. 2005; 293:293 Sexual Alcohol Motor Guns Drug Obesity/ Smoking Behavior Vehicle Induced Inactivity Also suffer from mental illness and/or substance abuse * * 435

29. © 2012 BHWP29 “All smokers with psychiatric disorders, including substance use disorders, should be offered tobacco dependence treatment, and clinicians must overcome their reluctance to treat this population” (Fiore et al., 2008, p. 154). 29 2008 Tobacco Dependence Clinical Practice Guideline

30. © 2012 BHWP30 Health Consequences of Smoking U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General, 2014. Cancers: – Acute myeloid leukemia – Bladder and kidney – Cervical – Colon, liver, pancreas – Esophageal – Gastric – Laryngeal – Lung – Oral cavity and pharyngeal – Prostate ( ↓survival) Pulmonary diseases: – Acute (e.g., pneumonia) – Chronic (e.g., COPD) – Tuberculosis Cardiovascular diseases – Abdominal aortic aneurysm – Coronary heart disease – Cerebrovascular disease – Peripheral arterial disease – Type 2 diabetes mellitus Reproductive effects – Reduced fertility in women – Poor pregnancy outcomes (ectopic pregnancy, congenital anomalies, low birth weight, preterm delivery) – Infant mortality; childhood obesity Other effects: cataract; osteoporosis; Crohn’s; periodontitis,; poor surgical outcomes; Alzheimer's; rheumatoid arthritis; less sleep

31. © 2012 BHWP31 Causal Associations with Second-hand Smoke Developmental –Low birth weight –Sudden infant death syndrome (SIDS) –Pre-term delivery -- Childhood depression Respiratory –Asthma induction and exacerbation –Eye and nasal irritation –Bronchitis, pneumonia, otitis media, bruxism in children –Decreased hearing in teens Carcinogenic –Lung cancer –Nasal sinus cancer –Breast cancer (younger, premenopausal women) Cardiovascular –Heart disease mortality –Acute and chronic coronary heart disease morbidity –Altered vascular properties USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General. There is no safe level of second-hand smoke.

32. © 2012 BHWP32 Medications that Smoking Decreases Blood Levels Brand Name Generic Name Elavil*Amitriptyline Anafranil*Clomipramine Aventyl/Pamelor*Nortiptyline Tofranil*Imipramine Luvox*Fluvoxamine Thorazine*Chlorpromazine Prolixin*Fluphenazine Haldol*Haloperidol Clorizaril*Clozapine Zyprexa*Olanzapine TylenolAcetominophen InderalPropanolol Slo-bid, Slo-Phyllin,Theophylline Theo-24, Theo-Dur, Theobid, Theovent Caffeine *Psychoactive medications

33. © 2012 BHWP33 Youth Smoking 1,000 American adolescents become regular tobacco users every day Early teen smokers with low nicotine exposure already show brain activation patterns of heavy adult smokers Youth smoking is associated with mental and addiction disorders later in life

34. © 2012 BHWP34 Never Too Late to Quit* Age of quitting smokingYears of life saved 25-3410 35-44 9 45-54 8 55-644 * Jha, NEJM Jan 24, 2013

35. Contact: Communications@TheNationalCouncil.org | 202.684.7457 Systems Changes: We Know What Works Raising tobacco taxes and price Tobacco-free indoor air laws and workplace tobacco bans State prevention and cessation initiatives (e.g. quit line) Combination of NRT and counseling Restriction of tobacco sales to minors Anti-tobacco counter-marketing efforts

36. Contact: Communications@TheNationalCouncil.org | 202.684.7457 www.TheNationalCouncil.org Going Tobacco-Free 36

37. © 2012 BHWP37 Barriers and Myths Poll 1.Should you do concurrent tobacco cessation & addiction treatment and/or MH treatment?

38. © 2012 BHWP38 Smoking & Behavioral Health: A Health Disparity Issue Elevated prevalence of use Targeted marketing by the tobacco industry Serious health consequences Significant costs & social isolation Enabling environments Lower access to treatment Inadequate research base

39. © 2012 BHWP39 Major Target Market 44% to 46% of cigarettes consumed in the U.S. by smokers with psychiatric or addictive disorders (Lasser, 2000; Grant, 2002) 175 billion cigarettes and $39 billion in annual tobacco sales (USDA, 2004)

40. © 2012 BHWP40 Smoking Prevalence by MH Diagnosis 2007 NHIS data Schizophrenia 59.1% Bipolar disorder46.4% ADD/ADHD37.2% Current smoking: 1 MH31.9% 2 MH41.8% 3+ MH61.4% Grant et al., 2004, Lasser et al., 2000 Major depression 45-50% Bipolar disorder 50-70% Schizophrenia 70-90%

41. © 2012 BHWP41 Usually if a person has not started smoking by age 20, it is unlikely they will ever smoke. However, a significant number of adults start smoking while in treatment/recovery, suggesting the treatment climate is conducive to smoking.* Unintended Consequences of Addictions Treatment * Friend & Pagano, 2004

42. © 2012 BHWP42 Myths Individuals with mental illness don’t want to quit Individuals with mental illness can’t quit o False – can and do quit at a rate slightly lower than the general population Treating tobacco use concurrent is detrimental to recovery and/or mental illness o False – increase sobriety by 25%* *Prochaska, et. al., 2006

43. © 2012 BHWP43 Just as Ready to Quit Smoking as the General Population

44. © 2012 BHWP44 Smokers with Bipolar Disorder: Online Survey (N=685) Few reported a psychiatrist (27%), therapist (18%), or case manager (6%) ever advised them to quit smoking (Prochaska, Reyes, Schroeder, et al. (2011). Bipolar Disorders) Several reported discouragement to quit from mental health providers

45. © 2012 BHWP45 Need for Smoking Intervention Tobacco treatment needs to be a higher priority for behavioral health. While focusing on addictions and mental health, clinicians sometimes miss this more deadly condition. Addressing tobacco use can improve health, ease pain, and save lives.

46. Leadership Activity If we’re moving towards integrated care, within your sphere of influence, how will you incorporate tobacco control & prevention efforts targeting people with SMI? How will you address the specific needs of priority populations (i.e., racial/ethnic minorities, low SES, rural/frontier, and LGBT)?

47. Leadership Activity How are you incorporating tobacco cessation activities as part of your KHF implementation plan?

48. Leadership Activity Would you push for tobacco cessation & what is your role as a leader within your organization? Who’s responsible for ensuring that tobacco control efforts meet the needs of SMI populations? In treatment settings? In public health? In communities? And How do we implement this? Would you push for tobacco cessation efforts for SMI populations…

49. Name 1 thing you learned from this exercise. Name 1 thing that you will do when you go home to improve tobacco control efforts. Report Out from Leadership Activity

50. © 2012 BHWP50 Questions and Answers

51. © 2012 BHWP51 Contact US! Shelina Foderingham ShelinaF@thenationalcouncil.org ShelinaF@thenationalcouncil.org 202-684-7457, ext. 272 Christine Cheng ccheng@medicine.ucsf.edu 415-476-0216 or toll free, 877-509-3786

52. © 2012 BHWP52 Indoor Smoking Room Kinston Psychiatric Hospital, NJ