Transcript The Ripple Effect: Smoking in Behavioral Health

Carlo DiClemente, Ph.D. & Meagan Graydon, M.A.
NAMI Maryland
2015 Annual Conference
Saturday, October 17, 2015
 The Maryland Resource Center for Quitting
Use and Initiation of Tobacco (MDQuit)
 Funded by the Maryland Department of
Health and Mental Hygiene (DHMH) and
located on UMBC campus
 Dedicated to assisting providers and
programs in reducing tobacco use among
citizens across the state utilizing best
practices strategies
Today’s Objectives
I.
II.
III.
IV.
V.
Overview of Tobacco Use in the U.S.
Tobacco Use & Behavioral Health
Second and Third-hand Smoke
Benefits of Smoke-free Policies
What Can Family Members Do?
“Cigarette smoking is the chief,
single, avoidable cause of death in
our society and the most important
public health issue of our time.”
~C. Everett Koop, M.D.
former U.S. Surgeon General
The Big Picture:
U.S. Tobacco Use
 In the U.S., 42.1 million people currently smoke
cigarettes (17.8% of adults). Of these…
 3 out of 4 smoke DAILY (77%)
 More than half of these daily smokers tried to quit in the past
year (52.9%)
 Between 1965 and 2009 the proportion of former
smokers more than doubled
 In 2012, 55% of ever smokers are now former smokers
 Smoking prevalence has dropped from 42% in 1965 to 17.8% in
2013.
CDC, 2014
Behavioral Health Populations
 Behavioral Health includes individuals at risk or
suffering from mental, behavioral, and/or addictive
disorders.
 They are a special population in tobacco use
research, because of their:
 Higher smoking prevalence than the general population of
smokers
 Disproportionate tobacco-related health disparities
 Lack of access to treatment
 Underrepresentation in prospective, longitudinal treatment
trials
Tobacco Disproportionately Impacts
Substance Use Populations
 Smoking rates are estimated to be as high as 74%
to 88% among individuals with substance abuse
problems
 Estimates range between 85% to 98% for individuals in
Methadone-Maintenance programs
 Individuals who abuse substances…




Tend to start smoking at a younger age
Are more likely to be heavy smokers
Are more nicotine dependent
Experience greater difficulty with quitting
Kalman, 1998 ; Holbrook & Kaltenbach,
2011; Prochaska et al., 2004
Tobacco Disproportionately Impacts
Mental Health Populations
 Tobacco use among persons with mental illness is
2 to 4 times as great as among the general U.S.
population
“In general, the more severe the psychiatric
condition, the higher the smoking prevalence.”
Prochaska et al., 2013;
Schroeder & Morris, p. 299, 2010
2010 Smoking Rates by Age Group in Maryland
Addiction/Mental Health Clients
Percentage of Smokers
~ 70% of individuals entering Addiction Treatment and ~40% of
individuals receiving Mental Health Services are Current Smokers
Effects of Smoking
(DHHS, 2014)
U.S. Deaths Attributable to
Smoking Annually
Lung Cancer
130,659
Other Diagnoses
61,141
About
480,000
Other Vascular
Diseases
11,500
U.S. Deaths
Attributable Each
Year to Cigarette
Smoking
Cerebrovascular
Disease (Stroke)
15,300
•
(DHHS, 2014)
Other Heart Disease
25,500
COPD
100,600
Coronary
Heart
Disease
99,300
Other Cancers
36,000
Average annual number of deaths 2005–2009
(DHHS, 2014)
Mortality: Tobacco and
Behavioral Health
 Individuals with chronic mental illness die on average 25
years earlier than the general population
 Top 3 causes of death: CVD, lung disease, and diabetes mellitus
 In a 20 year longitudinal study of individuals with
alcoholism or SUDs
 Mortality rate was 48%. Triple the expected 18%!
 HALF the deaths were attributed to smoking
 Each year, 200,000+ of the 480,000 deaths due to smoking
are believed to be among individuals with mental health
or substance use disorders.
Mauer, 2006; Hurt et al., 1996; Prochaska
et al., 2013
Secondhand and
Third-Hand Smoke
What is Secondhand Smoke?
• Inhalation of smoke from tobacco
products by people other than
the intended user
• Contains at least 7,000 chemicals
• Can occur in two forms:
• Side stream smoke – smoke burning from
cigarette
• Exhaled mainstream smoke – smoke exhaled
from lungs
(CTFK, 2011; DHHS, 2010; DHHS, 2006)
“Secondhand smoke causes premature
death and disease in children and in
adults who do not smoke.”
~U.S. Surgeon General’s Report
(DHHS, 2006; 2014)
Effects of Secondhand Smoke Exposure
(DHHS, 2014)
Exposure and Health Effects: Adults
 Any amount of exposure to tobacco smoke is
harmful
 Secondhand smoke has been found to cause heart
and lung disease in non-smoking adults.
Annually:
33,950 deaths due to heart disease
7,330 deaths due to lung cancer
(DHHS, 2014)
Exposure and Health Effects: Children
 According to WHO (2013), worldwide an
estimated
 40% of children have at least one
parent who smokes
 50% of children regularly breathe air
polluted by tobacco smoke in public
places
 SHS contributes to:
 Increased risk of asthma attacks
 More frequent missed days of school
 Increased risk of respiratory infections
(e.g. pneumonia, bronchitis)
 Hospitalizations
(WHO, 2013; CDC,
2014a; CDC, 2014b)
Preventing Exposure to SHS
 In 2007, the WHO suggested that a 100%
smoke-free environment should be
implemented to prevent effects of
secondhand smoke. At minimum:
 Keep the household or workplace smoke-free
 Prohibit smoking in vehicles that transport
children
 Do not smoke in the child’s room or any
room with a child present
 In 2014, the Surgeon General’s report stated,
 “There is no safe level of exposure to
tobacco smoke. Any exposure to tobacco
smoke-even an occasional cigarette or
exposure to secondhand smoke is harmful.”
(CDC, 2012; DHHS, 2014;
WHO, 2007)
What is Third-hand Smoke?
 The persistence of tobacco smoke pollutants in dust and
on surfaces after tobacco has been smoked.
 The residues of third-hand smoke can linger on the skin, clothes, and
furniture of individuals who smoke.
 Pollutants can remain in the environment for weeks to
months after the act of smoking occurs.
 Three main exposure routes to Third-hand smoke:
 Involuntary inhalation
 Ingestion
 Dermal uptake
(Singer et al., 2002;
Singer et al., 2004)
Exposure to Third-hand Smoke
 Children are at greatest risk for exposure:
 Spend more time indoors
 Ingest more dust
 Are closer to the floor
 Tend to place objects in their mouth
 Breathe faster
 Less-developed immune system
 Pets are also highly affected by second & third-hand
smoke, particularly if they spend most of the time indoors
(Bertone et al., 2002; Reif et al.,
1998; Drehmer et al., 2012)
Preventing Exposure to Third-hand
Smoke
 Third-Hand Smoke
 Efforts should be taken to enforce
strict smoking bans within
households, vehicles, and in the
proximity of indoor areas

Consider a Smoke-free Policy!
 Cleaning and ventilation help, but
are not enough to eliminate
exposure
(Drehmer et al., 2012;)
Preventing Exposure to Nicotine
Poisoning
 Nicotine Poisoning
 Acute nicotine poisoning can occur if a child ingests any
tobacco/nicotine product (e.g. cigarette butts, e-cigarette
liquid) or if nicotine is absorbed through skin or eyes.
 Keep all products containing nicotine (tobacco products,
NRT) out of the reach of children

If exposure is suspected, call Poison Control: 1-800-222-1222
 Symptoms of nicotine poisoning
include:
 Palpitations
 Sweating
 Agitation, restlessness, or excitement
 Confusion
 Muscular twitching
 Convulsions
 Burning sensation in the mouth
 Fainting
 Drooling
 Weakness
(NIH, 2014; CDC, 2014)
Benefits of Smoke-Free
Policies
Health Impacts of Smoke-Free Policies
 Reviews of smoke-free policies/legislation have
found significant health benefits, including:
 Reduction of pre-term births and hospital attendance
for asthma by 10%
 Increased cessation-related behavior among
smokers—including decreased cigarette consumption
and increased quit rate.
 Decreased rates of indoor smoking by 42%
 Fewer residential fires
(V Been et al., 2014; Pizacani
et al., 2012; Messer et al.,
2008)
Health Impacts of Smoke-Free Policies:
Secondhand Smoke Exposure
 Secondhand smoke exposure among nonsmokers in the
home decreased by 24%
Remember Smoke Gets Around!
 In multiunit housing, a significant proportion of SHS
found in smoke-permitted units travels to nonsmoking
areas:
 64.3% of levels found in smoke-permitted units found in the
hallways
 34.9% of levels found in smoke-permitted units found in smoke-free
units
(King et al., 2010)
Economic Impact of Smoke-Free Policies
Smoke-free policies can save you and society money!
 Reduce health care and loss of life costs
 Reduce health/home owners insurance premiums
 Limit liability for property owners
 Reduce property maintenance costs
General
Cleaning
No Smoking
Light Smoking
Heavy Smoking
$240
$500
$720
Plus, there is now an increasing demand for smoke-free housing!
(DHHS, 2014; LRC, 2012; Smokefree Housing New England, 2009)
What Can YOU Do?
If You’re Ready to Quit…
 Develop a Quit Plan
 Set a quit date
 Know your cessation options


Remember-BH clients often need
more intensive treatment!
Discuss cessation medications
with your doctor
 Get Support
 Recruit family and friends to
assist your quit attempt
 Refer to Cessation Resources
If You’re Ready to Quit…
Remember…
 Individuals with mental health conditions and addictive
disorders are interested in quitting and can quit with
appropriate support
 They may require more extensive support when quitting,
so be patient
 NRT and/or medications are recommended to aid in the
quit attempt
 Family and provider support will be critical to support
quit attempts
If You’re Ready to Quit…
…Know Your Options
 Nicotine Replacement Therapy (NRT):



Gum*
Patch*
Nasal Spray
– Inhaler
– Lozenge*
(*Available OTC)
 Dosages and preferences of products/combinations may vary
across individuals, take a collaborative approach!
 Medications:
 Bupropion (Zyban; Wellbutrin SR)
 Varenicline (Chantix)
Guided use of medications is recommended!
Resources: The Maryland Tobacco
Quitline
Maryland residents can receive FREE
and confidential smoking cessation
phone counseling by:
Calling the State Quitline at
1-800-Quit Now (1-800-784-8669)
Or visiting www.smokingstopshere.com
Maryland Tobacco Quitline Services
 Operates 24 hours a day / 7 days a week
 Free reactive and proactive phone coaching calls (4 calls)
 Extended services for pregnant women (10 calls) and adolescents (5
calls)
 Certified CoachesTM provide individually-tailored quit plans
 Free NRT (patch and/or gum) 12 week supply (Adults Only)
 Additional online and text to quit services!
 Provides referrals to local county resources – cessation
classes, in-person counseling and free medication
Additional Resources
 Local Health Departments
 Smoking cessation services and medication may be
available
 Nicotine Anonymous- www.nicotine-anonymous.org/
 A 12-step program to overcome nicotine addiction
 Other resources (hospitals, community organizations,
etc.)
If You’re NOT Ready to Quit…
…Implement a Smoke-free Policy
 “At present, the only means of effectively eliminating
health risks associated with indoor exposure is to ban
smoking activity.” - American Society of Heating,
Refrigerating & Air Conditioning Engineers (ASHRAE)
 It is NOT enough to:





Move to another room when smoking
Turn on a fan
Open a window
Blow smoke away from those not smoking
Use air fresheners or candles
These strategies can help reduce passive smoke exposure, but they
will not eliminate it!
(CDC, 2012)
Maintaining a Smoke-Free Home
 To minimize smoke exposure in your home, use
these strategies when going smoke-free:
 Keep the household smoke-free, including visitors
 Prohibit smoking in vehicles that transport any non-
smoker, particularly children
 Do not smoke in the child’s room or any room with a
child present—consider smoking ONLY outside
(WHO, 2013;
CDC, 2012)
If You have Family Members who
Smoke…
 Be supportive:
 40% of former smokers report that support from
family and friends was integral to their success!
 Talk to Tobacco-Using Family Members
 Strategies to Increase Motivation
 The 4 E’s
 Refer to Cessation Resources
(smokefree.gov)
If You have Family Members who
Smoke…
 12 Tips to Help a Loved One Quit:
1. Understand that quitting is hard
2. Know your relationship style
3. Start the conversation
4. Ask questions
5. Listen
6. Don’t lecture
7. Offer distractions
8. Be patient and positive
9. Don’t be too hard on them if they slip
10. Celebrate successes (big and small)
11. Help them de-stress
12. Be there for the long haul
(smokefree.gov)
If You have Family Members who
Smoke…
Whether or not someone is ready to quit using tobacco,
there are some strategies you, as a family member or
friend, can use to encourage them to begin thinking about
making a quit attempt or to support their decision to quit
These strategies can be simplified into the “4
 Engage
 Educate
 Encourage
 Empathize
E’s”:
Engage
• Start a caring and respectful conversation.
Express your concerns about their smoking.
• Allow them to express to you what they enjoy
about smoking and their fears about quitting.
• If they are prepared to quit, ask how you can
help them reach their smoke-free goal and let
them know you will give them the support they
need.
•
Otherwise, continue to listen!
Educate
 Rather than focus on risks and dangers of
smoking, help them see the benefits of quitting:
 Improvements in health
 Improvements in physical appearance
 Save money
 Freedom from the addiction
 You may also want to make them aware of how
secondhand smoke can affect other family
members, including pets!
Encourage
• Express confidence in their ability to quit
smoking.
• Congratulate them on any progress they make—
big or small!
• If they make a quit attempt, celebrate their
progress along the way.
•
If the person begins smoking again (lapse or relapse),
encourage them to try again, and praise them for their
effort in each and every attempt until it sticks!
Empathize
• Imagine the magnitude of the challenge facing the
person who is interested in or trying to quit, and
be patient with them as they struggle to overcome
their addiction.
• Remember, they may truly enjoy parts about their
smoking and this is a major lifestyle change for
them.
Putting it All Together
 Behavioral health populations smoke at a higher rate
and often require more intensive treatment for
smoking cessation.
 The good news: Quitting is possible!
 If you want to quit now, there are many resources
available to support your quit attempt.
 If you’re not ready, you can still take steps toward keeping
you and your family members healthy.
 If you have a loved one who smokes, you can be a
positive source of support with a few key strategies
in mind.
Contact Us
UMBC
Department of Psychology
1000 Hilltop Circle, Baltimore, MD 21250
P: (410) 455-3628
F: 410-4551755
E: [email protected]
Web: www.mdquit.org