Transcript Tobacco: Key Contributor to Early Death in Mental Health

Tobacco: Key Contributor to Early Death
in Mental Health
Stephen S. Michael, MS
Director, ASHLine
2012 U.S. Public Health Service Scientific & Training Symposium
Washington, DC
June 20, 2012
1:30 – 2:00 pm
Mental Illness in the U.S.
Substance Abuse and Mental Health Services Administration, Results
from the 2010 National Survey on Drug Use and Health: Mental
Health Findings, NSDUH Series H-42, HHS Publication No. (SMA) 114667. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2012.
Serious Mental Illness in the U.S.
Substance Abuse and Mental Health Services Administration, Results
from the 2010 National Survey on Drug Use and Health: Mental
Health Findings, NSDUH Series H-42, HHS Publication No. (SMA) 114667. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2012.
Treatment Services
Substance Abuse and Mental Health Services Administration, Results
from the 2010 National Survey on Drug Use and Health: Mental
Health Findings, NSDUH Series H-42, HHS Publication No. (SMA) 114667. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2012.
Mental Illness & Mortality
• In the U.S. individuals with serious mental
illness die, on average, 25 years prematurely.
• Suicide is NOT the most common reason for
death.
Myths About Smoking & Mental Illness
• Tobacco is necessary self-medication
(Tobacco industry has fostered this myth)
• They are not interested in quitting
(Just as likely to want to quit as general population)
• They cannot quit
(Tailored programs can have cessation rates similar to the general population)
• Quitting interferes with recovery from the mental illness
(Research indicates this is not the case)
• It is a low priority problem
(Smoking is a leading cause of death in behavioral health populations)
Factors Contributing to the Disparity
• Psychiatrists are less likely to ask about smoking, arrange follow-up,
and refer to a quitline than other physicians.
• Behavioral health professionals are not usually trained in smoking
cessation.
• Behavioral health treatment settings are often exempted from
workplace smoking regulations.
• A recent in-depth study of eight drug treatment programs found
that although a number of programs reported they offer
counseling, pharmacotherapy, and other key components of
evidence-based tobacco treatment, few actually provided any
treatment and none did so systematically (Hunt et al., 2012).
Barriers To Tobacco Free lifestyles
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Lack of hope
Failures and Fears
Loneliness
The Illness itself
Lack of Skills & Knowledge & Support
Poverty
Low Expectations
Why???
“Where is the OUTRAGE?!”
Dori Hutchinson, Sc.D – Director of Services
Center for Psychiatric Rehabilitation
Sargent College of Health and Rehabilitation Sciences
Boston University
A Hidden Epidemic:
Tobacco Use and Mental Illness
Legacy® – June 2011
– Issues of the high prevalence of tobacco use and
nicotine dependence among people with mental
illnesses.
– Barriers to effective tobacco-cessation efforts to help
people with mental illnesses quit.
• Education and training of mental health providers
in evidence-based tobacco cessation
• Integration of tobacco prevention and cessation
into mental health care
http://www.legacyforhealth.org/PDF/A_Hidden_Epidemic.pdf
Prevalence of Psychiatric Disorders
and Nicotine Dependence
• 22% of adults in US have a chronic mental illness and/or
substance use disorder.
• Clients with mental illness have 2-4 times rates of
nicotine dependence than the general population.
• Psychiatric populations represent 44-46% of the U.S.
tobacco market, consume 34-44% of all cigarettes
smoked, and spend up to 27-40% of their income on
cigarettes.
Lasser et al (2000); Kisely & Campbell (2008); Steinberg et al (2004); Schroeder &
Morris (2010)
Smoking Prevalence among Adults by
Lifetime Mental Illnesses Compared to
General Population
70
Schizophrenia
Percentage
60
Bipolar Disorder
50
Serious Psychological Distress
40
30
Attention Defict Disorder
20
Dementia
10
Phobia or Fears
0
Lifetime Mental Illness
Source: McClave et al 2010
General Population
Nicotine Dependence in Psychiatric
Patients
 Individuals with schizophrenia are 3X more likely to be
smokers, 50% are heavy smokers (> 25 cigarettes/d) and
13X more likely to smoke high-tar cigarettes than patients
with other psychiatric disorders.
 Nicotine-dependent psychiatric patients have increased
mortality from cardiovascular and respiratory disorders,
lung cancer, infections, and diabetes.
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Persons with mental illness die younger – 25 years earlier than
the general population
20% shorter life span
Tobacco is the leading preventable cause of death
Kisely & Campbell (2008); Schroeder & Morris (2010)
Psychiatric Comorbidity and Tobacco Use
• Individuals with mental illness have neurobiological
causes that increase their tendency to use nicotine and
other substances and make it more difficult to quit.
– Addiction, dependence, and tolerance
– Self-medication of nicotine withdrawal
• Nicotine may:
– Enhance concentration, information processing, learning, and
mood
– Reduce medication side effects
– Exacerbate comorbid psychiatric conditions
– Act as a gateway drug to cocaine (mice) - Levine et al (2011)
Barriers for Tobacco Cessation
• Mental health professionals attitudes towards smoking
– Treatment plans do not address nicotine dependence
– In smoke-free psychiatric units – patients are
frequently not offered nicotine replacement therapy
– Only 1 out of 100 smokers (inpatient psychiatry) are
encouraged to stop smoking or referred to a formal
cessation program or provided NRT on discharge
• Psychiatrists are less likely to offer smoking cessation
counseling/interventions than primary care physicians
(12% vs 38%)
Kisely & Campbell (2008)
Frequency of Smoking-Cessation Services Provided by
Psychiatrists Compared to Those Provided by Family Physicians
Source: American Association of Medical Colleges, Physician Behavior
and Practice Patterns Related to Smoking Cessation
Percentage
Psychiatrists
Family Practitioners
86
62
14
19
2
Ask about Smoking Status
Arrange Follow Up Visits
9
Refer to a Quitline
US Public Health Service Key
Recommendations
1) Clinicians should strongly recommend the use
of effective tobacco dependence counseling
AND discuss medications with their patients
who use tobacco
2) Health care systems, insurers, and purchasers
should assist clinicians in making such
effective treatments available
Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and
Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of
Health and Human Services. Public Health Service. June 2008.
Tobacco Use and Dependence: 2008 Update
• All smokers with psychiatric disorders, including
substance use disorders, should be offered tobacco
dependence treatment.
– Clinicians must overcome their reluctance to treat this
population.
• Clinicians may wish to offer the tobacco dependence
treatment when psychiatric symptoms are not severe.
• Stopping tobacco use may affect the pharmacokinetics
of certain psychiatric medications.
• Stopping smoking or nicotine withdrawal may
exacerbate a patient’s comorbid condition.
DHHS Tobacco Use and Dependence 2008 Update, p.153-4.
Tobacco Use and Dependence: 2008 Update
• Antidepressants (i.e. bupropion SR, nortriptyline) are
effective in increasing the long term cessation rates
in smokers with a past history of depression (when
coupled with intensive psychosocial interventions).
• Bupropion SR and NRT may be effective for treating
smoking in persons with schizophrenia and may
improve negative symptoms of schizophrenia and
depression.
DHHS Tobacco Use and Dependence 2008 Update, p.146.
Treatment Approaches
 Brief interventions
 Motivational enhancement therapy
 Medications for tobacco cessation
 Nicotine replacement (gum, lozenge, patch, nasal spray, oral inhaler)
 Non-nicotine: bupropion, varenicline (FDA approved)
 Second-line non-nicotine: clonidine, nortriptyline (non-FDA approved)
 Non-drug therapies
 Individual based
 Cognitive behavioral therapy (CBT)
 Smokers Helpline – Coaching and Support
 Group based: peer-to-peer, self-help
 Community based
 Program based (e.g., smoke-free units)
Importance of Counseling
• Smokers with drug, alcohol or mental disorders are more
likely to quit smoking if they receive counseling/coaching
• Healthy habits for living longer
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Stopping smoking
Drinking alcohol moderately
Reducing caffeine intake
Exercising regularly
Eating a healthy diet
Stress reduction
Decreased risk for medical and psychiatric disorders
Lower mortality rates
Treatment Considerations:
Recognize Different Modes of Intervention
• Inpatient/Residential (onsite cessation
interventions)
• Intensive Treatment Settings (onsite cessation
interventions with quitline support)
• Outpatient Treatment Settings (quitline cessation)
• Case Management/Medication Management
(quitline cessation)
Why Include a Quitline?
Feds Require every State to have one:
1-800-QUITNOW
Because they WORK!
Example: ASHLine (Comprehensive)
• Inbound telephone calls
answered by tobacco
coaches
• Self-help (mail & web)
• Proactive, multi-call
program
• Medication assistance
Messages to Providers
(Recovery Agents)
• Tobacco Cessation is a treatment
issue, not a lifestyle choice.
• You don’t allow people to drink or
use illicit drugs on campus, why
tobacco?
• People with mental health
challenges REALLY DO want to
quit tobacco.
ASHLine Mission
“Improve the health of Arizonans by providing clientcentered tobacco cessation services through technology
based interventions.”
Integrating Tobacco Treatment
• Legacy
http://www.legacyforhealth.org/PDF/A_Hidden_Epidemic.pdf
• Smoking Cessation for Persons with Mental Illness: A
Toolkit for Mental Health Providers
www.tcln.org/bea/docs?Quit_MHToolkit.pdf
• Tobacco-Free Living in Psychiatric Settings: A BestPractices Toolkit Promoting Wellness and Recovery
www.nasmhpd.org/general_files/publications/NASMHPD.toolkit.FINAL.pdf
• UCSF – Education and Training
http://smokingcessationleadership.ucsf.edu/BehavioralHealth.htm
http://rxforchange.ucsf.edu
Schizophrenia and Smoking
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2X risk of cardiovascular mortality
3X risk for respiratory disease and lung cancer
Risk factors for morbidity/mortality:
– Obesity, poor nutrition, sedentary lifestyle, poor health care
Heavy smokers vs. light smokers
– More positive symptoms and less negative symptoms
– Fewer EPS symptoms
– Increased substance abuse
– More frequent hospitalizations
– Increased suicide risk
– Increased risk of polydipsia
Aguilar et al (2005); Ziedonis et al (1994, 2008)
Alcoholics and Smoking
• 10 times greater risk of pancreatitis than non-smokers
• 3 times greater risk of cirrhosis
• 38 times greater risk of developing mouth and throat
cancer than non-smokers and non-drinkers
• Chronic cigarette smoking increases the severity of brain
damage associated with alcohol dependence
Bipolar Patients and Smoking
• Many patients with bipolar disorder report smoking to
help treat the symptoms of mental illness.
• Most want to quit smoking and many are actively
planning or trying to quit smoking.
• Few are advised to quit smoking by a mental health
provider.
• Most have made multiple attempts to quit, many unaided
with cessation medications or counseling.
• Quitting smoking is associated with mental health
recovery.
Prochaska et al (2011) – online survey
Substance Abuse and Smoking
• 75% of people (> 12 yrs) in substance abuse treatment
smoke cigarettes
Substance Abuse and Mental Health Services Administration:
www.samhsa.gov
• Smoking cessation interventions and treatment
– 25% increase in long-term abstinence from alcohol
and illicit drugs
– Incorporating smoking cessation into treatment for
alcohol and drug abuse does not jeopardize recovery
– Eliminating tobacco use is associated with decreased
use of other abused substances (12 studies)
Prochaska et al (2004); Baca & Yahne (2009)
Thank You
Stephen S. Michael, MS
(520) 320-6819
[email protected]
Arizona Smokers’ Helpline (ASHLine)
Zuckerman College of Public Health
University of Arizona