Transcript Smoking Cessation - National Treatment Agency for Substance

Substance Misuse
Smoking Cessation Pilot:
Implementation and Interim Findings
Dr Gordon Morse – Medical Director
Neesha Chand – Special Projects Manager
The need…
(thanks to Lynda Bauld)
Smoking and substance
misuse (APMS, 2007)
Smoking and Substance Misuse
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Smokers’ higher subjective symptoms of
methadone inadequacy (Tacke et al, 2001)
Smoking impedes cognitive recovery after
alcohol abstinence (Kalman et al, 2010)
Smokers require higher doses of some
benzodiazepines/opiates (RCP, 2013)
Examples of health impacts
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Cohort study of 845 substance misuse patients
in Minnesota, US:
222 died during study
 214 with death certificates: 51% documented a
tobacco-related cause of death, > than proportion
from alcohol & other drug-related causes (Hurt et al,
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1996)
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Tobacco and alcohol use multiplies risk of
developing cancers of upper respiratory &
digestive tracts (Pelucchi et al, 2007; Kalman et al, 2010; Baca &
Yahne, 2009)
Staff and client attitudes
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Staff rated nicotine dependence treatment significantly
less important than treatment of other substances
53% (n=88) staff thought addressing smoking should
be put off until late or after a client’s primary addiction
treatment & only 29% (n=40) thought it should be
addressed early in treatment
By contrast, nearly half of clients thought it should be
addressed early in treatment
Average rating of staff confidence in supporting
someone who wanted to give up (on a 10 point scale)
was 7.0 but varied considerably
Treatment
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Smoking cessation doesn’t impact negatively on success
of abstinence from other substances; may improve
outcomes
Meta-analysis of 19 RCTs of smoking-cessation
interventions for people in substance misuse treatment
and in recovery showed concurrent treatment of
smoking resulted in a 25% increased likelihood of
long-term abstinence from alcohol and illicit drugs
(Prochaska et al, 2004)
Khara & Okoli, 2011; Burling et al, 2001; Kalman et al, 2010; Baca & Yahne 2009; Williams &
Ziedonis, 2004; Prochaska et al, 2004; Stapleton et al, 2009; Goulay et al, 1994; Moore & Budney,
2001; Prochaska et al, 2004; Stuyt, 1997; Weinberger & Sofuoglu 1997
Treatment
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Most studies demonstrate that adding smoking
cessation therapy to substance abuse treatment
programs yields higher overall drug and alcohol
abstinence (Tsoh et al, 2011)
Rationale: Discontinuance of one drug (nicotine)
can support abstinence from other drugs due to
shared neurobiological mechanisms (Baca & Yahne,
2009)
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However, smoking cessation programmes
exclusively addressing tobacco are less effective
for cannabis users (Stapleton et al, 2009)
Adverse Childhood Event (ACE)
study - 1998
asked 26,000 consecutive adults coming through
Kaiser Permanente’s Department of Preventive
Medicine in San Diego, California if they would be
interested in helping us understand how childhood
events might affect adult health status. Seventyone percent agreed (17,421) - mean age 57
ACE Scores:
growing up in:
 a household where someone was in prison
 where the mother was treated violently
 with an alcoholic or a drug user
 where someone was chronically depressed, mentally ill,
or suicidal
 where at least one biological parent was lost to the
patient during childhood – regardless of cause
 recurrent physical abuse
 recurrent severe emotional abuse
 contact sexual abuse
An individual exposed to none of the categories had an ACE Score of 0; an
individual exposed to any four had an ACE Score of 4, etc.
Illicit Drug use
Licit Drug use - tobacco
NICE recommendations include:
 Identifying people who smoke and
offering and arranging support
 Implement a comprehensive smoke free
policy that includes the grounds
 Support for staff smokers
 Training for staff
Building on & sharing best practice
 Turning Point, PHE, South London and Maudsley NHS
Foundation Trust (SLAM)
 National Centre for Smoking Cessation Training (NCSCT)
 9 smoking cessation substance misuse service pilot sites
 Share learning from the pilot that with other providers
and commissioners considering introducing or
expanding smoking cessation
Senior management steer
Smoking Cessation Project Tiers
 SC Project Group: Jan Hernen (Clinical Psychologist),
Neesha Chand (Project Lead), Darren Woodward
(Project Sponsor)
 SC Working Group: Area Operation Managers (sign up
to deliver action plan per pilot site)
 Smoking Cessation Leads: (operationally develop and
deliver local action plans)
Methodology
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benchmark service user smoking prevalence
benchmark workforce attitudes and behaviour
train & engage staff
review smoking policies
design interventions (assessment and goal planning)
record activity and outcomes
evaluate the pilots
1. SU prevalence
 TP benchmarking data extracted from April 2014 to
February 2015 in the nine pilot areas for
– SU smoking status (currently smoking, had previously
smoked and had never smoked)
– Data completeness or missing smoking status
 Comparative data to be extracted after one year to
test and demonstrate pilot outcomes
2. Workforce attitudes &
behaviour
Team quiz & anonymous staff survey key findings
 Most staff are open to including brief advice on
smoking cessation and signposting into treatment as
part of their interventions
 Most staff already feel confident that they have the
skills to support smokers to stop
 There is a high level of staff receptiveness to the idea of
cessation
3. Train & engage staff –
consider timeline for launch
4. Review smoking policies
Service user and local service protocols – SUI
Peer mentor and volunteer local protocols
Staff – manager guidance documents – including
breaks, e-cigarettes / vaping
Staff wellbeing policies – improve direct access
“Staff working in substance misuse services are about twice as
likely to smoke as the general population. The desire by two
thirds of them to stop is a good indication of a need for
substance misuse services to put on ‘stop smoking’ services for
their own staff.” Don Lavoie, PHE
5. Design interventions
 Develop in conjunction with staff
 Consider how it will be recorded and monitored
 Keep changes minimal – essential questions only for
behaviour change and outcome measurements
 Changes made to core TP paperwork
– TP Assessment
– NTA Goal Planner
Prompts – Assessment
Have you ever smoked tobacco?
 Never
 Currently
 Previously
If currently or previously smoked, how many times have you tried to give up in last 12
months?
How many cigarettes do you smoke per day?
Out of last 28 days how many have you smoked?
If you currently smoke, would you like support to give up or cut down on your tobacco
smoking?
Offered and Accepted – Support Offered:
 Very Brief Advice
 Nicotine Replacement Therapy
 Referral to internal (TP provided) smoking cessation service
 Referral to external smoking cessation service
 Other
Do you smoke e-cigarettes?
 Yes or  No
If so, how many times in a typical day do you smoke an e-cigarette?
Prompts – Recovery Planning
6. Data recording
 All activity & outcomes recorded on CIM (Client
Information Management) System – inconsistent
 Activity
– Smoking Assessment
– Interventions (VBA & specialist level 2/NRT)
– Referrals (specialist level 2/NRT)
 Outcomes
– Outcome section in CIM
– 'Successful - No Longer Smoking‘ (new field)
7. Interim findings
 Activity has increased but recording is inconsistent
 Where commissioned KPI’s in place uptake is higher
 Mandatory fields would help with compliance – internal
exception reporting required (TOPS)
 Working groups and management steer is essential
 September 2015 – pilot evaluation will include
 Comparative data (Apr to Aug) improvements in
identification and interventions
 Sampling – assess impact of smoking cessation on
substance misuse treatment outcomes
Pilot outcome
 Integrated smoking
cessation & substance
misuse provision…
 Improved access to
smoking cessation for
service users AND staff
 Interventions being
delivering internally and
signposted to externally