Quit MHToolkit

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Table o ContentsOverview1 AlarmingStatistics 1

2 AboutthisToolkit: 2

Whoisthistoolkitor?HowdoIusethistoolkit?

Tobacco Use and Mental Illness

1 SmokingandMentalIllness: 3 BiologicalPredispositions,PsychologicalConsiderations,

SocialConsiderations,Stigma

2 SpecicMentalDisorders: 4

Depression,Schizophrenia,OtherDisorders

3 TobaccoIndustryTargeting 5

Assessment and Intervention Planning

1 ReadinesstoQuitandStagesoChange: 7 StagesoChange,The5As(Flowchart,Actionsand

Strategies),The5Rs(AddressingTobaccoCessationor

TobaccoUserUnwillingtoQuit)

2 CulturalConsiderations: 13

RecommendationsorMentalHealthClinician,Resources

Smoking Cessation Treatment or Persons

with Mental Illness1 KeyFindings 152 ComponentsoSuccessulIntensiveInterventionPrograms 16

3 BehavioralInterventionsorSmokingCessation: 17

Overview,SANEprogram,MoreElementso

SuccessulCounseling

4 PrescribingCessationMedications: 19

Depression,Schizophrenia,BipolarDisorder

Relapse Prevention1 ComponentsoMinimalPracticeRelapsePrevention 23

2 ComponentsoPrescriptiveRelapsePrevention 23

Local and National Tobacco Cessation Resources 25


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Funding or this project was provided by:Tobacco Disparities Initiatives o the State Tobacco Education and Prevention

Partnership (STEPP), Colorado Department o Public Health and the Environment

The Tobacco Cessation Toolkit or Mental Health Providers was developed

by the University o Colorado at Denver and Health Sciences Center,

Department o Psychiatry:

Chad Morris, Ph.D.

Jeanette Waxmonsky, Ph.D.

Alexis Giese, M.D.Mandy Graves, MPH

Jennier Turnbull

For urther inormation about this toolkit, please contact:

Jeanette Waxmonsky, Ph.D

University o Colorado at Denver and Health Sciences Center

4455 East 12th Avenue, A011-11

Denver, Colorado 80220

Phone: 303.315.9155

Fax: 303.315.9343

Email: [email protected].


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Overview

1 AlarmingStatistics

2 AboutThisToolkit:

Whoisthistoolkitor?

HowdoIusethistoolkit?


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O V E R V I E W | 1

Why is a smokingcessation toolkit orpersons with mentalillnesses needed?

They need to quit.Consumersneedtobealivetorecoverrommental

illnesses.Smokingcessationisakeycomponento

consumer-driven,individualizedtreatmentplanning.

They want to quit.Peoplewithmentalillnesseswanttoquitsmokingand

wantinormationaboutcessationservicesandresources.(Morrisetal,2006)

They can quit.Peoplewithmentalillnessescansuccessullyquit

usingtobacco.(Evinsetal.,2005;Georgeetal.,2002).

Signicantevidenceshowsthatsmokingcessation

strategieswork.

Note:Throughoutthistoolkitthetermstobaccouse

andsmokingareusedinterchangeably.Althoughwedo

notspecicallyaddressspit-tobaccouse,thetoolkitis

generallyapplicabletospit-tobaccousers.

Id love to quit I just dont know how. John, age 45


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O V E R V I E W | 2

Alarming StatisticsApproximately 7.7 percent o

Colorados adult population has a major

mental illness.1

Forty-onepercentotheseindividualsusetobacco.

Theprevalenceosmokingamongpeoplewith

mentalillnessesisstartling.

By diagnosis:Majordepression 45-50percent

Bipolarmooddisorder 50-70percent

Schizophrenia 70-90percent

Americanswithmentalillnessesrepresentan

estimated44.3percentothetobaccomarket. 2

Americanswithmentalillnessesarenicotine

dependentatratesthataretwotothreetimes

higherthanthegeneralpopulation. 3

Becausepeoplewithmentalillnessesusetobacco

atgreaterrates,theysuergreatersmoking-related

medicalillnessesandmortality.4

About this toolkitWho is this toolkit or?Thistoolkitwasdevelopedorabroadcontinuum

omentalhealthproviders.Materialsareintended

ordirectproviders,aswellasadministratorsand

behavioralhealthorganizations.

How do I use this toolkit?Thetoolkitcontainsavarietyoinormationand

step-by-stepinstructionabout:

Lowburdenmeansoassessingreadiness

toquit

Possibletreatments

ReerraltoColoradocommunityresources

1] Morris et al., 2006

2] Grant et al., 2004, Lasser et al., 2000

3] Grant et al., 2004, Lasser et al., 2000

4] Grant et al., 2004


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Quick FactsMental Illnesses and Tobacco Use

7.1%otheU.S.populationhasapsychiatricillness;however,thispopulation

consumesover34.2%oallcigarettes.(Grantetal.,2004)

IntheU.S.,personswithmentalillnessesrepresentanestimated44.3%othetobacco marketandarenicotinedependentatratesthatare2-3timeshigherthanthegeneral population.(Grantetal.,2004;Lasser,2000)

InColorado,approximately7.7%otheadultpopulationhasamajormentalillnessand 41%otheseindividualsusetobacco.(Gieseetal.,2003)

Smokingcessationisakeycomponentoconsumer-driven,individualizedtreatment

planning.(Morrisetal.,2006)

Personswithmentalillnesseswanttoquitsmokingandwantinormationoncessation servicesandresources.(Morrisetal.,2006)

Personswithmentalillnessescansuccessullyquitusingtobacco.(Evinsetal.,2005; Georgeetal.,2002)

SmokingquitratesorindividualswithpsychiatricillnessareNOTsignifcantlylower thanthegeneralpopulation.(el-Guebalyetal.,2002)

Becausepersonswithmentalillnessesusetobaccoatgreaterrates,theysuergreater smoking-relatedmedicalillnessesandmortality.(Grantetal.,2004)

References:

El-GuebalyN,CathcartJ,CurrieSetal(2002).Smokingcessationapproachesorpersonswithmentalillnessoraddictivedisorders.

Psychiatric Services,53(9):1166-1170.

EvinsAE,MaysVk,RigottiNA,etal.(2001).Apilottrialobupropionaddedtocognitivebehavioraltherapyorsmokingcessationin

schizophrenia.Nicotine Tobacco Research,3(4):397-403.

GeorgeTP,VessicchioJC,TermineAetal.(2002b).Aplacebo-controlledstudyobupropionorsmokingcessationinschizophrenia.Biological Psychiatry,52(1):53-61.

GieseA,MorrisC,OlincyA(2003).Needsassessmentopersonswithmentalillnessesortobaccoprevention,exposure,reduction,

andcessation.ReportpreparedortheStateTobaccoEducationandPreventionPartnership(STEPP),ColoradoDepartmentoPublic

HealthandEnvironment.

GrantBF,HasinDS,ChouPS,StinsonFS,DawsonDA(2004).NicotinedependenceandpsychiatricdisordersintheUnitedStates:

resultsromthenationalepidemiologicsurveyonalcoholandrelatedconditions.Archives General Psychiatry,61(11):1107-1115.

LasserK,BoydW,WoolhandlerS,etal(2000).Smokingandmentalillness:apopulationbasedprevalencestudy. Journal o the

American Medical Association,284:26062610.

MorrisCD,GieseJJ,DickinsonM,Johnson-NagelN.(2006).PredictorsoTobaccoUseAmongPersonsWithMentalIllnessesina

StatewidePopulation.Psychiatric Services,57:1035-1038.


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TobaccoUseandMentalIllness

1 SmokingandMentalIllness:

BiologicalPredispositions

PsychologicalConsiderations SocialConsiderations

Stigma

2 SpecifcMentalDisorders:

Depression

Schizophrenia

OtherDisorders

3 TobaccoIndustryTargeting


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Smoking and mental illnesses:nicotine eects and other considerationsPeoplewithmentalillnesses:

usetobaccoathigherrates

arelesslikelytosucceedatcessationattempts

accessgeneralmedicalservicesandother

communityresourcesrelativelyinrequently

strugglewithstigmaonseverallevels

generallyexperienceagreaterburdenomorbidity

andmortalitythantheoverallpopulation.

Why do they smoke more?Researchersbelievethatacombinationobiological,

psychologicalandsocialactorscontributetoincreased

tobaccouseamongpersonswithmentalillnesses.

Biological predisposition

Personswithmentalillnesseshaveuniqueneurobiologicaleaturesthatmayincreasetheirtendencytousenicotine,

makeitmorediculttoquitandcomplicatewithdrawal

symptoms.

Nicotineaectstheactionsoneurotransmitters

(e.g.dopamine).Forexample,peoplewithschizophrenia

whousetobaccomayexperiencelessnegative

symptoms(lackomotivation,driveandenergy).

Nicotineenhancesconcentration,inormationprocessing

andlearning.(Thisisespeciallyimportantorpersons

withpsychoticdisordersorwhomcognitivedysunction

maybeapartotheirillnessorasideeecto

antipsychoticmedications).

Otherbiologicalactorsincludenicotinespositiveeectsonmood,eelingsopleasureandenjoyment.

Someevidencesuggeststhatsmokingisassociatedwith

areducedriskoantipsychotic-inducedParkinsonism.

T O B A C C O U S E a n d M E N T A L I L L N E S S | 3

Tobacco useand mental illness


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Psychological considerationsTobaccousemaytemporarilyrelieveeelings otensionandanxietyandisotenusedtocope

withstress.

Peopledevelopadailyroutineosmoking.

Social considerationsPeoplemaysmoketoeelpartoagroup.

Smokingisotenassociatedwithsocialactivities.

Personswithmentalillnessesmaynothavealot

oactivitiestokeepthembusy.Whentheyre

bored,theymaysmokemore.

Thesiteoasocialactivitymaysupport

tobaccouse.

StigmaProvidersotenthinkthatpeoplewithmental

illnessesareunabletoquitsmoking.Symptommanagementotentakesprecedence

overpreventivehealthmeasures.

Specifc mental disordersWhataresomeconsiderationsorsmokingcessationinregardtospecicmentaldisorders?

Depression

Amongpatientsseekingsmokingcessation

treatment,25-40percenthaveahistoryomajor

depressionandmanyhaveminordysthymic

symptoms.

Depressionhasbeenshowntopredictpoorer

smokingcessationrates.Considerstartingor

restartingpsychotherapyorpharmacotherapyor

depressioninpatientswhostatethatdepression

intensiedwithcessationorthatcessationcaused

depression.

Cognitivebehavioraltherapyordepressionandantidepressantshasbeenoundtoimprovesmoking

cessationratesinthosewithahistoryodepression

orsymptomsodepression.

Forasmokerwithahistoryodepressioncurrently

takingantidepressantmedication,itisimportantto

notethatsomeantidepressantlevelswillincrease

withsmokingcessation.

Stress is a big

trigger or me.I dont know how

to deal with stress. Cathi, age 32

What I did to keep rom

craving cigarettes or a while

is just to keep busy, being

with people, and talking andplaying games and working

and things like that. Thats

what helped me.


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Schizophrenia

Personswithschizophreniawhosmokemaybeless

interestedintobaccocessation,makingstrategies

toenhancemotivationtoquitespeciallyimportant.

Whenmentalhealthconsumerswithschizophrenia

dotrytostop,manyareunsuccessul;thus,

intensivetreatmentsareappropriateevenwith

earlyattempts.

Thehighprevalenceoalcoholandillicitdrugabuse

inconsumerswithschizophreniacanintererewith

smokingcessation.

Thebloodlevelsosomeantipsychoticscan

increasedramaticallywithcessation.Nicotine

withdrawalcanmimictheakathisia,depression,

dicultyconcentratingandinsomniaseeninconsumerswithschizophrenia.

Other psychiatric disorders

Thereisinsucientinormationtomakespecic

recommendationsabouttailoringtreatmento

smokingcessationtotheneedsosmokerswith

otherpsychiatricdisorders.

Ingeneral,whenmentalhealthconsumersmakean

attemptatsmokingcessation,theyshouldbe

ollowedcloselytomonitorormoreseverenicotine

withdrawal,exacerbationotheirpsychiatricdisorder

andpossiblesideeectsduetocessation-induced

increasesinmedicationlevels.

Methylphenidate(Ritalin)andd-amphetamine

(Dexedrine),stimulantscommonlyprescribedor

behavioralproblemsassociatedwithattentiondecit

hyperactivitydisorder(ADHD)increaserateso

smokingandthereinorcingeectsosmoking.

Methylphenidateandd-amphetamineuseinearlylie

leadstoincreasedoddsodailysmokinglaterinlie.

Tobacco industry targeting

By1977,smokerswerebecomingadownscalemarket.RJReynoldsnotedthatlesseducated,

lowerincome,minoritypopulationsweremore

impressionable/susceptibletomarketingand

advertising.Tobaccocompaniesbegantargeting

thesepopulations.Free cigarettes were

distributed to homeless shelters, mental

hospitals and homeless service organizations.

Cigaretteswerepurchasedorthementallyillandhomelesssothatconsumerswouldsmokeclean

cigarettes,notdirtycigarettesbutts.

Thetobaccoindustryhastargetedpsychiatric

hospitalsorsalespromotionsandgiveaways.

Theyhavemadenancialcontributionstohomeless

veteranorganizations,usingrelationshipsto

advancetheirpoliticalagenda.


Ive been schizophrenic since I was 14. I was told more less when I wentto the hospitals that cigarettes help control certain areas in my brain and

the way we unction out in society. I more or less became more o a

smoker because I was told it would help me with my illness. I was taught

more about it helping my illness than I was about cancer and stu


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Notes

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AssessmentandInterventionPlanning

1 ReadinesstoQuitandStagesoChange:

StagesoChange

The5As(Flowchart,ActionsandStrategies)

The5Rs(AddressingTobaccoCessationor

TobaccoUsersUnwillingtoQuit)

2 CulturalConsiderations:

RecommendationsorMentalHealthClinicians

Resources


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Readiness to quit and stages o changeTheStagesoChangeModel(alsoknownastheTranstheoreticalModel)illustratedbelowisuseulin

recognizingthatnicotinedependenceisachronic,

relapsingdisorderwithmosttobaccousersinthegeneral

populationrequiringvetosevenattemptsbeorethey

nallyquitorgood.Manypatientsdonotrealizethatit

usuallytakesseveralattemptstostopusingtobaccoand

willneedmotivationtoattempttoquititheyhavebeen

unsuccessulinthepast.Itisuseultothinkotobacco

cessationasaprocessratherthananevent.

Onceapersonhasbeenidentiedasatobaccouser,

hisorherreadinesstoquitcanbedetermined.This

isimportantbecausetobaccouserswhoarenot

consideringquittingappeartoneeddierentinterventions

thanthosewhoareambivalentaboutquittingorthose

presentlyinterestedinquitting.TobaccousersinthePrecontemplationstage(notconsideringquitting)canbe

movedtotheContemplationstagebyaskingconsumers

toconsiderthenegativeconsequencesotobaccouse

orthemandtheadvantagesotobaccocessation(this

inormationhastobepersonalized).Itisworthwhile

toactivelyencouragequittingandoersupportand

treatmentaswellasconveyingthemessagethatpersons

withmentalillnessescansuccessullyquitusingtobacco.

Stages o changePrecontemplation:Nochangeisintendedinthe

oreseeableuture.Theindividualisnotconsidering

quitting.

Contemplation:Theindividualisnotpreparedtoquitat

present,butintendstodosointhenextsixmonths.

Preparation:Theindividualisactivelyconsidering

quittingintheimmediateutureorwithinthenext

month.

Action:Theindividualismakingovertattemptstoquit.

However,quittinghasnotbeenineectorlongerthan

sixmonths.

Maintenance: The individual has quit or longer than

A S S E S S M E N T a n d I N T E R V E N T I O N P L A N N I N G | 7

Assessmentand intervention planning


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The 5 As:

Ask, Advise, Assess, Assist and ArrangeTheU.S. Public Health Service Clinical Practice

Guideline: Treating Tobacco Use and Dependence

provideshealthcarecliniciansastrategyorsmoking

cessationtreatmentthatisbuiltaroundthe5As

(Ask,Advise,Assess,AssistandArrange).Knowing

thatprovidershavemanycompetingdemands,the

5Aswerecreatedtokeepstepssimple.

Ontheollowingpagesyouwillndasummaryo

theseeasilyimplementedsteps.

TheGuidelinerecommendsthatallpeopleentering

ahealthcaresettingshouldbeaskedabouttheir

tobaccousestatusandthatthisstatusshouldbe

documented.Providersshouldadvisealltobacco

userstoquitandthenassesstheirwillingnesstomakeaquitattempt.Personswhoarereadyto

makeaquitattemptshouldbeassistedinthe

eort.Followupshouldthenbearrangedto

determinethesuccessoquitattempts.

Theull5Asmodelismostappropriateoragencies

andorganizationsthathavetobaccocessation

medicationsand/orbehavioralservicesavailableorconsumers.Foragenciesandorganizationsthat

donothavetobaccocessationservicesreadily

available,werecommendtheuseothersttwo

As(askandadvise)andthenrefertoavailable

communityservices.Theull5Asmodel,aswellas

theabbreviatedask-advise-reermodelare

presentedinthefowchartandtablesatthebacko

thisbook.

ASK

AD

VIS

E

AS

SE

SSASS

IST

AR

RAN

GE

Tobacco dependenceand use (current or ormer)

is a chronic relapsing

condition that requiresrepeated interventions and

a systematic approach.

I you have limited time:

ASKADVISEREFER


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Strategies for Implementation

Clear:Asyourclinician,Iwanttoprovideyouwithsomeeducationabout

tobaccouseandencourageyoutoconsiderquittingtoday.

Strong:Asyourclinician,Ineedyoutoknowthatquittingsmokingisthemost

importantthingyoucandotoprotectyourhealthnowandintheuture.Theclinic

staandIwillhelpyou.

Personalized:Tietobaccousetocurrenthealth/illness,itssocialandeconomic

costs,motivationlevel/readinesstoquit,and/ortheimpactotobaccouseon

childrenandothersinthehousehold.

Seepatienteducationalbrochureatbackothismanual.

Action

Inaclear, strong and

personalizedmanner,

adviseeverytobaccouser

toquit.

Bemindultoadviseina

non-judgmentalmanner.

Action

Forconsumersinterestedin

quitting.


Provideinormationonlocalsmokingcessationresources.Youmayndlocal

resourcesathttp://www.co.quitnet.com/libraries/programs/.

Useproactivereerraliavailable:Requestwrittenconsumerpermissiontoaxtheir

contactinormationtotheColoradoQuitLineorotherprogram.Inormthepatient

thecessationprogramstawillcontactthem.

Action

Askeveryconsumerat

everyvisit,includinghospital

admissions,itheysmoke.


Withinyourpractice,systematicallyidentiyalltobaccousersateveryvisit.

Establishanocesystemtoconsistentlyidentiytobaccousestatusateveryvisit.

(Seeclinicexampleatendothissection.)

Determinewhatormotobaccoisused.

Determinerequencyouse.

Determinetobaccousestatus.

Makenoteoconsumersexposedtosecondhandsmoke.

Actions and Strategies or Mental Health Providers to Help Consumers Quit Smoking


ASK

REFER

ADVISE


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ActionAssesswillingnesstomake

aquitattemptwithinthenext

30days.

Determinewiththepatient

thecostsandbenetso

smokingorhimorher.

Determinewherethepatient

isintermsothereadiness

tochangemodel.

Assesspastquitattempts

andpast/currentpsychiatric

symptomsorconsumers

wantingtoquit.


Assessreadinessorchange.Gotop.7tolearnhowtoassessreadinessorchange.

Itheconsumerisreadytoquit,proceedtoAssist(below)and/orarrangeormore

intensiveservicestohelpwiththequittingprocess.

Itheconsumerwillparticipateinanintensivetreatment,deliversuchatreatmentor

reertoanintensiveintervention(Arrange).

Itheconsumerisntreadytoquit,dontgiveup.Providerscangiveeective

motivationalinterventionsthatkeepconsumersthinkingaboutquitting.Conducta

motivationalinterventionthathelpsconsumersidentiyquittingaspersonallyrelevantandrepeatmotivationalinterventionsateveryvisit.

Foraddressingtobaccocessationwithtobaccousersunwillingtoquit,please

proceedtothe5Rsonpage12.

Fortheconsumerwhoiswillingtoquit:

Obtainasmokinghistoryandassessexperiencewithpreviousquitattempts:

Reasonsorquitting.

Anychangeinpsychiatricunctioningwhenheorshetriedtostop?

Causeorelapse(wasthisduetowithdrawalsymptomsorincreased psychiatricsymptoms?)

Howlongdidheorsheremainabstinent?

Priortreatmentintermsotype,adequacy(dose,duration),complianceand

consumersperceptionoeectiveness.

Expectationsaboututureattemptsandtreatments.

Determinewhetherthereareanypsychiatricreasonsorconcernaboutwhetherthis

isthebesttimeorcessation:

Istheconsumerabouttoundergoanewtherapy?

Istheconsumerpresentlyincrisis,oristhereaproblemthatissopressingthat

timeisbetterspentonthisproblemthanoncessationatthisvisit?

Whatisthelikelihoodthatcessationwouldworsenthenon-nicotinepsychiatric

disorder?Andcanthatpossibilitybediminishedwithrequentmonitoring,useo

nicotinereplacementtherapyorothertherapies?

Whatistheconsumersabilitytomobilizecopingskillstodealwithcessation?

Ithecopingskillsarelow,wouldtheconsumerbenetromindividualorgroup

behaviortherapy?

Istheconsumerhighlynicotinedependentordoestheconsumerhaveahistory

orelapseduetowithdrawalsymptomsorincreasedpsychiatricsymptoms?Iso, whichmedicationmightbeohelp?

Increasingreadiness/motivation:Iaconsumerwithpsychiatricillnessisnotreadyto

makeaquitattempt,enhancemotivationanddealwithanticipatedbarriersto

cessation.

Useproblemsolvingstrategies.

Increase monitoring o tobacco se

A S S E S S M E N T a n d I N T E R V E N T I O N P L A N N I N G | 1 0

ASSESS


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Action

Helptheconsumerwitha

quitplan.

Recommenduseoapproved

nicotinereplacementtherapy

(NRT)and/orcounseling


Set a quit date,ideallywithintwoweeks.

Tellamily,riendsandcoworkersaboutquittingandrequestunderstandingand

support.

Anticipatetriggersorchallengestoplannedquitattempt,particularlyduringthe

criticalrstewweeks.Theseincludenicotinewithdrawalsymptoms.Discusshow

theconsumerwillsuccessullyovercomethesetriggersorchallenges.

Removetobaccoproductsromtheenvironment.Priortoquitting,consumershould

avoidsmokinginplaceswheretheyspendalototime(e.g.work,home,car).Forconsumerswithcognitivediculties(e.g.memoryorattentiondecits)dueto

mentalillness,havethemwritedowntheirquitplan,sotheycanreertoitlater.

RecommendtheuseoNRTmedicationstoincreasecessationsuccess.

Discussoptionsoraddressingbehavioralchanges(e.g.cessationclasses,

individualcounseling,telephonecoachingromtheColoradoQuitLine)

Encouragepatientswhoarereadytoquitthattheirdecisionisapositivestep.


ASSIST

Action

Scheduleollow-upcontact.


Timing.Followupcontactshouldoccursoonaterthequitdate,preerablywithin

therstweek.Asecondollow-upcontactisrecommendedwithintherstmonth.

Scheduleurtherollow-upcontactsasneeded.

Actionsduringollow-upcontact:

Congratulate success!Itheconsumerhasrelapsed,reviewthecircumstancesandelicitrecommitment

tototalabstinence.

Remindpatientthatalapsecanbeusedasalearningexperience.

Identiyproblemsalreadyencounteredandanticipatechallengesinthe

immediateuture.

AssessNRTuseandproblems.

Consideruseorreerraltomoreintensivetreatment.

Give positive feedback about the patients attempts to quit.

Individuals often cut down substantially on their tobacco use

before quitting, and this harm reduction needs to be recognized

and congratulated.

ARRANGE


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The 5 Rs: Addressing Tobacco Cessation

or the Tobacco User Unwilling to Quit(From Treating Tobacco Use and Dependence.

Quick Reference Guide for Clinicians, October 2000.

U.S. Public Health Service.

www.surgeongeneral.gov/tobacco/tobaqrg.htm)

The5RsRelevance,Risks,Rewards,Roadblocks

andRepetition,aredesignedtomotivatesmokers

whoareunwillingtoquitatthistime.

Smokersmaybeunwillingtoquitdueto

misinormation,concernabouttheeectsoquitting

ordemoralizationbecauseopreviousunsuccessul

quitattempts.Thereore,ateraskingabouttobacco

use,advisingthesmokertoquitandassessingthe

willingnessothesmokertoquit,itisimportantto

providethe5Rsmotivationalintervention.

Relevance

Encouragetheconsumertoindicatewhyquittingis

personallyrelevant,asspecicallyaspossible.

Motivationalinormationhasthegreatestimpactiit

isrelevanttoaconsumersmedicalstatusorrisk,

amilyorsocialsituation(e.g.,havingchildreninthe

home),healthconcerns,age,genderandotherimportantpatientcharacteristics(e.g.,priorquitting

experience,personalbarrierstocessation).

Risks

Asktheconsumertoidentiypotentialnegative

consequencesotobaccouse.Suggestand

highlightthosethatseemmostrelevanttothem.

Emphasizethatsmokinglow-tar/low-nicotine

cigarettesoruseootherormsotobacco(e.g.,

smokelesstobacco,cigarsandpipes)willnot

eliminatetheserisks.

Examplesorisksare:

Acuterisks:Shortnessobreath,exacerbationo

asthma,harmtopregnancy,impotence,inertility

andincreasedserumcarbonmonoxide.

Longtermrisks:Heartattacksandstrokes,lung

andothercancers(larynx,oralcavity,pharynx,

esophagus,pancreas,bladder,cervix),chronic

obstructivepulmonarydiseases(chronicbronchitis andemphysema),longtermdisabilityandneed

orextendedcare.

Environmentalrisks:Increasedriskolungcancer

andheartdiseaseinspouses;higherrateso

smokinginchildrenotobaccousers;increased

riskorlowbirthweight,SuddenInantDeath

Syndrome,asthma,middleeardiseaseand respiratoryinectionsinchildrenosmokers.

Every time I need a pack o

cigarettes, thats taking

money out o my pocket.

You can see everybody

around here, people that

arent smoking, look how

much money they have.

People that are smoking arepretty much broke. I I could

quit smoking, Id have more

money to spend.


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Rewards

Asktheconsumertoidentiypotentialbenetso

stoppingtobaccouse.Suggestandhighlightthose

thatseemmostrelevanttotheconsumer.

Examplesorewardsollow:

Improvedhealth

Foodtastesbetter

Improvedsenseosmell

MoneysavedBetterselimage

Home,car,clothing,breathsmellbetter

Nomoreworryingaboutquitting

Setagoodexampleorchildren

Havehealthierbabiesandchildren

Nomoreworryingaboutexposingothers

tosmoke

FeelbetterphysicallyPerormbetterinphysicalactivities

Reducewrinkling/agingoskin

Roadblocks

Asktheconsumertoidentiyimpedimentstoquitting

andnoteelementsotreatment(problemsolving,

medications)thatcouldaddressbarriers.

Typicalbarriersmightinclude:

Withdrawalsymptoms

Fearoailure

Weightgain

Lackosupport

Depression

Enjoymentotobacco

RepetitionRepeatmotivationalinterventionseverytimean

unmotivatedconsumervisitstheclinicsetting.

Tobaccouserswhohaveailedinpreviousquit

attemptsshouldbetoldthatmostpeoplemake

repeated quit attempts beore they are successul

Cultural ConsiderationsCulturalissuesshouldalsobeconsideredorthose

individualsodiverseracialandethnicbackgrounds

astobaccocessationassessmentandservicesare

oered.

Recommendations

KeyndingsromtheSurgeonGeneralsreport:

(1998SurgeonGeneralsReport,TobaccoUse

AmongU.S.Racial/EthnicMinorityGroups)

Intheourracial/ethnicgroupsstudied(Arican

American,AmericanIndian/AlaskaNative,Asian

American/PacicIslanderandHispanic),Arican

Americanmenbearoneothegreatesthealth

burdens,withdeathratesromlungcancerthatare

50percenthigherthanthoseoCaucasianmen.

Ratesotobaccorelatedcancers(otherthanlung

cancer)varywidelyamongmembersoracial/ethnic

groups.TheyareparticularlyhighamongArican

Americanmen.

Tobaccouseamongadolescentsromracialand

ethnicminoritygroupshasbeguntoincreaserapidly,

threateningtoreversetheprogressmadeagainstlungcanceramongadultsintheseminoritygroups.

CigarettesmokingamongAricanAmericanteens

hasincreased80percentoverthelastsixyears

threetimesasastasamongwhiteteens.

Thehighlevelotobaccoproductadvertisingin

racial/ethnicpublicationsisproblematicbecausethe

editorsandpublishersothesepublicationsmay

limitthelevelotobaccousepreventionandhealth

promotioninormationincludedintheirpublications.

Well, the frst thing is you have to decide is that youre really

committed to doing it and then you try over and over and overuntil you fnally get there, and eventually you get there.

But it takes a lot o time and its not easy. Sandy, age 37


21/55


Recommendations or Mental Health Clinicians

Whenworkingwithpersonswithmentalillnesseswhoarealsoodiverseracial/ethnicbackgrounds,themental

healthclinicianshould:

Ask,Advise,Assistand/orReerallpatientswithregardtotobaccocessation.Thereisacriticalneedto

delivereectivetobaccodependenceeducationandinterventionstoethnicandracialminoritieswith

mentalillnesses.

Usecessationinterventionsthathavebeeneectiveorpersonswithmentalillnesses(e.g.NRTorbuproprion

incombinationwithindividualorgroupcounselingthatemploysmotivationalinterviewingorcognitive- behavioralstrategies).Avarietyosmokingcessationinterventions(includingscreening,clinicianadvice,

sel-helpmaterialsandthenicotinepatch)havebeenproveneectiveortobaccocessationinminority

populations.

Beculturallyappropriate,refectingthetargetedracial/ethnicgroupsculturalvalues.Thismayincreasethe

smokersacceptanceotreatment.

Conveycessationcounselingorsel-helpmaterialsinalanguageunderstoodbythesmoker.

Resources

Formoreinormationabouttobaccouseandinterventionorracial/ethnicpopulationsinColorado,pleasesee

theollowingonlineresources:

ColoradoTobaccoDisparitiesStrategicPlanningWorkingGroup:http://ctdsp.amc.org/

ColoradoStateStateTobaccoEducationandPrevention(STEPP):http://steppcolorado.com

ColoradoMinorityHealthForumorInormationonReducingHealthDisparitiesinColorado:

http://www.coloradominorityhealthorum.org/


22/55

Example for Clinic Screening for Tobacco Use

From the U.S. Department of Health & Human Serviceshttp://www.surgeongeneral.gov/tobacco/tobaqrg.pdf

ACTION STRATEGIESforIMPLEMENTATION

Implementanofce-widesystem Expandvitalsignstoincludetobacco

thatensuresthat,oreverypatientat useoruseanalternativeuniversal everyclinicvisit,tobacco-usestatus identifcationsystem.

isqueriedanddocumented.

VITALSIGNS

BloodPressure:

Pulse: Weight:

Temperature: RespiratoryRate:

TobaccoUse(circleone):CurrentFormerNever

Repeatedassessmentisnotnecessaryinthecaseotheadultwhohasneverused

tobaccoorhasnotusedtobaccoormanyyears,andorwhomthisinormationis

clearlydocumentedinthemedicalrecord.

Alternativestoexpandingthevitalsignsaretoplacetobacco-usestatusstickerson

allpatientchartsortoindicatetobacco-usestatususingelectronicmedicalrecords

orcomputerremindersystems.

C l d Q itLi R f l F


23/55

ParticipantConsentforReleaseofInformationAuthorization to Release Inormation (refects the requirements o 45 C.F.R. 164.508 August 14, 2002)

I,___________________________________,givepermissiontomyhealthcareprovidertoreleasemy

name,phonenumber,anddateobirthtotheColoradoQuitLine(800-QUIT-NOW)quitsmoking/tobacco

programatNationalJewishMedicalandResearchCenter(contractorortheColoradoQuitLinecallcenter),

1400JacksonStreet,Denver,Colorado,80206.

ThePURPOSEothisreleaseistorequestthatNationalJewishMedicalandResearchCentermakean

initialphonecalltometodiscussparticipationintheColoradoQuitLineProgram.Iunderstandthe

inormationtobereleased,thepurposeothisrelease,andthattherearelawsprotectingconfdentialityo

inormation.Iunderstandthatoncereleased,myinormationmaybere-disclosed,andmaynolongerbe

protected.Iunderstandthatsigningthisormisnotaconditionoreceivingservices.

_________________________________________________________ Participant Signature Date

Thispatientmayusenicotinereplacementtherapy.

_________________________________________________________Provider Signature Date

For more NRT program information please go to http://www.steppcolorado.comor call 1.800.QUIT.NOW.

PLEASEFAXORMAILTHISSIGNEDFORMTO:

ColoradoQuitLineSpecialist Fax 1.800.261.6259

Mail ColoradoQuitLine

(Participantname)

ReferringProvider(stamp/label/writein)

Name

Clinic/Facility

Address

City/State/Zip

Phone#

Fax#*

*REQUIREDTORECEIVECONFIRMATIONOFREFERRAL

PatientInformation

Name_______________________________________

Address_____________________________________

City/State/Zip_______________________________

Phone#______________________DOB__________

Besttimeanddaytocall_____________________

DoyouneedTTY? YesNo

Mayweleaveamessage? YesNo

Colorado QuitLine Referral Form

1.800.QUIT.NOW(1-800-784-8669)FAX:800-261-6259

SignHere

SignHere


24/55

SmokingCessationTreatmentorPersonswithMentalIllnesses

1 KeyFindings

2 ComponentsoSuccessulIntensive

InterventionPrograms

3 BehavioralInterventionsorSmokingCessation:

Overview

SANEProgram

MoreElementsoSuccessulCounseling4 PrescribingCessationMedications:

Depression

Schizophrenia

BipolarDisorder

S M O K I N G C E S S A T I O N T R E A T M E N T | 1 5


25/55

Key fndingsSmokingcessationmodelsorpersonswithmental

illnessesgenerallycombinenicotinereplacementtherapy

(NRT)withCognitiveBehavioralTherapy(CBT),atypeo

psychotherapythatocusesonchangingdysunctional

thoughts,emotionsandbehavior.

CBTprogramsthatproducethemostsuccessulquit

ratesorthementalhealthpopulationgenerallyhave

groupsoapproximately8-10individualsthatmeetonceaweekor7-10weeks.

Consumerswithschizophreniaseemtohavethehighest

successwhenCBTiscombinedwithNRTandstrategies

toenhancemotivation.Arandomizedcontrolstudyby

Bakeretal.(2006)oundthatatallollow-upperiods,

asignicantlyhigherproportionosmokerswitha

psychoticdisorderwhocompletedalltreatmentsessionswerecurrentlyabstinent,relativetoacomparisongroup

opersonsreceivingcareasusual,(pointprevalence

rates:3months,30.0%vs.6.0%;6months,18.6%

vs.4.0%;12months18.6%vs6.6%).Smokerswho

completedalleighttreatmentsessionswerealsomore

likelytohaveachievedcontinuousabstinenceatthree

months(21.4%vs.4.0%).

Thereisastrongdose-responserelationbetween

thesessionlengthoperson-to-personcontactand

successultreatmentoutcomes.Intensiveinterventions

aremoreeectivethanlessintensiveinterventionsand

shouldbeusedwheneverpossible.

Haugetal.(2005)oundthatorpeoplewithdepression,

smokingcessationwasbestpredictedbystageo

change,withthoseinpreparationenteringtreatment

morequicklythancontemplatorsorprecontemplators.

Thevariablesmostassociatedwithacceptingtreatment

werenotseverityosymptoms,butrathercurrentuseo

psychiatricmedicationsandperceivedabilitytosucceed

in quitting

Smokingcessation treatment or personswith mental illnesses



26/55

Components o Successul Intensive

Intervention Programs:Intensivecessationinterventionsshouldincludethe

ollowing(romtheU.S.DepartmentoHealthand

HumanServices,2000):

Assessment

Assessmentsshouldensurethattobaccousersare

willingtomakeaquitattemptusinganintensive

treatmentprogram.Otherassessmentscanprovideinormationuseulincounseling(e.g.stresslevel,

presenceopsychiatricsymptoms,stressors,other

comorbidity).Personswithmentalillnesseswhoare

attemptingtoquitsmokingshouldbecareully

assessedandmonitoredordepressionandother

psychiatricsymptomsateveryocevisit.

Program clinicians Multipletypesocliniciansareeectiveandshould

beused.Onecounselingstrategywouldbetohave

amedical/healthcarecliniciandelivermessages

abouthealthrisksandbenetsanddeliver

pharmacotherapy,andbehavioralhealthclinicians

deliveradditionalpsychosocialorbehavioral

interventionslikecognitivebehavioraltherapy(CBT).

Program intensity

Becauseoevidenceoastrongdose-response

relationship,theintensityotheprogramshouldbe:

Sessionlengthlongerthan10minutes.

Numberosessions4ormore.

Totalcontacttimelongerthan30minutes.

Program ormat

Eitherindividualorgroupcounselingmaybeused.

Proactivetelephonecounselingalsoiseective.

Useoadjuvantsel-helpmaterialisoptional.

Follow-upassessmentinterventionprocedures

shouldbeused.

Type o counseling and behavioral therapies

Counselingandbehavioraltherapiesshouldinvolvepracticalcounseling(problemsolving/skillstraining),

aswellasintra-treatmentandextra-treatment

socialsupport.

Pharmacotherapy

Everysmokershouldbeencouragedtouse

pharmacotherapies,exceptinthepresenceo

specialcircumstances.Specialconsiderationshouldbegivenbeoreusingpharmacotherapy

withselectedpopulations(e.g.pregnancy,

adolescents).Theclinicianshouldexplainhow

thesemedicationsincreasesmokingcessation

successandreducewithdrawalsymptoms.

Therst-linepharmacotherapyagentsinclude:

bupropionSR,nicotinegum,nicotineinhaler,

nicotinenasalsprayandthenicotinepatch.(SeePharmacotherapiesSectiononp.19and

laminatedsheetatbackothismanual).



27/55

Behavioral Interventions or

Smoking CessationUseobriepsychosocialinterventions,sel-helpand

supportivetherapyhavebeenshowntobeeective

withgeneralmedicalpatientsbutmaynotbe

sucientorconsumerswithpsychiatricproblems

(APA,1996).Additionally,peoplewithmental

illnessesotenhaveewersocialsupportsand

copingskills.Thereore,intensivebehavioraltherapy

shouldbeconsideredorthesepeopleevenintheearlyquitattempts.Whenpossible,themental

healthprovidershouldelicitconsumerpreerences

aboutgrouporindividualtherapy.Iaconsumerhas

aspecicissuethatmightunderminetobacco

cessation(e.g.problemswithassertiveness),the

mentalhealthprovidermightworkonthisissuein

individualtherapywhiletheconsumeralsoattends

grouptherapyortobaccocessation.

Cessationprogramsorpeoplewithmentalillnesses

includeabout7-10sessions.Typically,thereis

anintroductiontotobaccohistoryandprevalence

ouse

educationaboutthepropertiesonicotine,health

eectsonicotineandaddictivenatureonicotine

areviewothereasonswhypeoplesmokeeducationaboutwaysonecanquitsmoking,use

omedicationanddevelopmentoaquitplan.

Asnotedabove,additionalsessionsareuseulor

addressingissuesthatarepertinenttopersonswith

mentalillnesses(i.e.,developingcopingskillsor

stressandanxiety).

TheSANEprograminAustralia(Strasser,2001)

isoneeectivegroupcounselingprogramorpersonswithschizophrenia.Itinvolvesteaching

problemsolvingskillsandcognitive-behavioral

techniquestoaidsmokingreductionandcessation

maintenance.Thegroupconsistso10sessions,

runbytwotrainedacilitators.Thecontentconsists

otheollowing:

IntroductiontotheProgram

ReasonstoQuitBenetsoQuitting

UnderstandingWhyWeSmokeandWays

oQuitting

WithdrawalSymptoms

SocialSupport

DealingwithStressandAnxiety

CopingwithDepression

AssertivenessTrainingAngerManagement

Smoke-FreeLiestyle

DealingwithHighRiskSituations

More Elements o Successul Counseling

Furtherelementsosuccessulcounselingand

supportiveinterventionsareoutlinedintheollowing

tables(U.S.DepartmentoHealthandHuman

Services,2000).



28/55

Practical counseling

treatment component

(problems solving/skills

training

Recognizedangersituations:

Identiyevents,stressors,

internalstatesoractivitiesthat

increasetheriskosmokingorrelapse.

Developcopingskills:

Identiyandpracticecoping

orproblemsolvingskills.

Providebasicinormation

aboutsmokingand

successulquitting.

Examples

Negativemood

Psychiatricsymptoms

Beingaroundothersmokers

DrinkingalcoholorusingdrugsExperiencingurges

Beingundertimepressure

Learningtoanticipateandavoidtemptation.

Learningcognitivestrategiesthatwillreducenegativemoods.

Accomplishingliestylechangesthatreducestress,improvequalityolieor

producepleasure.

Learningcognitiveandbehavioralactivitiestocopewithsmokingurges(e.g.

distractingattention).

Anysmoking(evenasinglepu)increasesthelikelihoodoaullrelapse.

Withdrawaltypicallypeakswithin1-3weeksaterquitting.

Withdrawalsymptomsincludenegativemood,urgestosmokeanddiculty

concentrating.

Inormationontheaddictivenatureosmoking.

Common elements o practical counseling

Additionally, sta and peer support are key actors in cessation counseling.

Some common elements o each:

Supportive treatment

component

Encouragethepatientinthe

quitattempt.

Communicatecaringand

concern.

Encouragetheconsumer

totalkaboutthequitting

Examples

Sharethateectivetobaccodependencetreatmentsarenowavailable.

Notethatone-haloallpeoplewhohaveeversmokedhavenowquit.

Communicatebelieintheconsumersabilitytoquit.

Askhowtheconsumereelsaboutquitting.

Directlyexpressconcernandwillingnesstohelp.

Beopentotheconsumersexpressionoearsoquitting,dicultiesexperienced

andambivalenteelings.

Askabout:

Reasonstheconsumerwantstoquit.



29/55

Common elements o eliciting peer support and other resources

Supportive treatment

component

Trainconsumersinsupport

solicitationskills.

Promptsupportseeking.

Arrangeoutsidesupport.

Examples

Showvideotapesthatmodelskills.

Practicerequestingsocialsupportromamily,riendsandcoworkers.

Aidconsumerinestablishingasmoke-reehome.

Helpconsumeridentiysupportiveothers.

Calltheconsumertoremindhimorhertoseeksupport.Inormconsumersocommunityresourcessuchasquitlines.

Mailletterstosupportiveothers.

Callsupportiveothers.

Inviteotherstocessationsessions.

Assignconsumerstobebuddiesoroneanother.

Prescribing Cessation MedicationsUtilizetherequencyomentalhealthtreatmentvisits

asanopportunityormonitoringprogressin

smokingcessation.Additionally,smokingcessation

strategiesshouldbeintegratedandcoordinated

withtreatmentsormentalillnesses.

Sincepeoplewithmentalillnessesappeartohave

morewithdrawalsymptomswhentheystop

smokingthanthegeneralpopulation,theuseonicotinereplacementtherapy(NRT)eveninearly

cessationattemptsisrecommended.

TheoptimaldurationoNRTisnotknown.Some

individualsappeartorequirelong-termuseoNRT

(e.g.,6months),butalmostallindividuals

eventuallystopusingNRTandthedevelopmento

dependenceonNRTisrare.Thus,patientpreerenceshouldbethemajordeterminateorthe

durationoNRT(American Psychiatric Association

Practice Guidelines 2006: Treatment of Patients with

Substance Use Disorders,2ndEdition,p54).

Depression

Considerbuproprionandnortriptylineorconsumerswithdiagnosesodepression.

Bupropion-SRhasbeendemonstratedtobethe

mosteectiveindepressedpatients.Patientswho

usebupropion-SRduringasmokingcessation

programaremorelikelytobeabstinentatthequit

date.However,relapseishighollowingthe

discontinuationotreatment(Evins,etal.,2005;

George,etal.,2002).Additionally,bupropion-SRhashadadverseaectsonpatientswithbipolar

disorderand/orahistoryoeatingdisorders.It

shouldnotbeusedinthesepopulations(McNeill,

2004).Additionalresearchonsmokerswitha

historyodepressionsuggeststheuseulnessothe

nicotinetransdermalpatch(Thorsteinssonetal.,

2001)andnicotinegum(Kinnunenetal.,1996)or

short-termsmokingcessation.

Stronglyconsiderbehavioraltherapiessuchas

CognitiveBehavioralTherapy(CBT),assmokers

withdepressionarelikelytoailwithmoreminimal

interventions(Brownetal,2001).Improved



30/55

Schizophrenia

Smokingcessationprogramsthatusethenicotinetransdermalpatch(NTP)demonstratethehighest

quitratesorpatientswithschizophrenia(Williams&

Hughes,2003)asitaidsinwithdrawalsymptoms.

WhentreatmentincludestheuseoNRTinpatients

withschizophrenia,Dalacketal.(1999)oundthat

dyskinesiasdecreasedduringabstinenceinthe

placebopatchcondition,butincreasedduring

abstinenceintheactivepatchcondition.

NRTisassociatedwithsmokingcessationrateso

27percentto42percentinsmokerswith

schizophrenia(Addingtonetal.,1998;Chouetal.,

2004;Georgeetal.,2000).Also,useonicotine

nasalspray,whichproducesthehigherplasma

levelsonicotine,isassociatedwiththereductiono

withdrawalandcraving(Williamsetal.,2004).

Incontrolledtrials,pharmacologicaltreatmentwith

sustained-release(SR)bupropionhasbeen

ecaciousinpromotingabstinenceinpersonswith

schizophrenia.Treatment-seekingsmokershave

shownsuccess(withshort-termabstinencerateso

11percentto50percent)withacombinationo

bupropionSRandcognitive-behavioraltherapy

(CBT)atboththe150mg/day(Evinsetal.,2001)

andthe300mg/daydoses(Evinsetal.,2005;

Gerogeetal.,2002).Bupropiontreatmentalso

seemstoreducethenegativesymptomso

schizophrenia(Weinberberetal.,2006).

Patientstreatedwithatypicalantipsychoticagents,

suchasclozapine(Clozaril),smokeless(Georgeet

al.,1995;McEvoyetal.,1999,1995)andhaveaneasiertimequitting(Georgeetal.,2002,2000)than

thosetreatedwithtypicalantipsychoticmedications.

However,smokingcessationcancauseachangein

plasmaconcentrationsopsychotropicagentsdue

to a decrease in the induction o cytochrome P450

(Modecate),haloperidol(Haldol),andolanzapine

(Zyprexa).Thereore,monitoringmedicationsideeectsmaybeneededduringtherstmonthater

quitting(Kalmanetal.,inpress;Ziedonisand

George,1997).Themetabolismorisperidone

(Risperdal)andquetiapine(Seroquel)doesnot

appeartobeaectedbysmoking(Strasser,2001).

Bipolar Disorder

Glassmanetal.(1993)oundthatpersonswithbipolardisorder(BD)mayalsobeatriskor

recurrenceodepressivesymptomsduringsmoking

cessation.Interestingly,personswithBDshowa

geneticlinkagetothea7nAChRnicotinicreceptor

locusonchromosome15similartothatoundor

personswithschizophrenia(Leonardetal.,2001).

Todate,therehavebeennoempiricallybased

treatmentspublishedorsmokerswithBD

(Weinberger,etal,2006).UseoNTPissuggested

orthispopulation.

Anxiety Disorders

Althoughpatientsreportthatsmokingreduces

depressionandanxiety,chronicnicotineusein

animalstudiesispositivelycorrelatedwithincreased

anxiety(Irvineetal.2001).Itisuncleartowhat

extentsmokersexperiencewithdrawalsymptoms

andmisinterpretareductioninnicotinewithdrawal

asanxietyrelie(ZiedonisandWilliams,2003).

Cinciripiniandcolleagues(1995)oundthatsmokers

withhighlevelsotraitanxietyreceivingbuspirone

(BuSpar)versusplaceboweremorelikelytohave

remainedabstinentattheendothetrialbutnotat

ollow-up.AsnotedbyWeinbergeretal.,(2006),a

placebo-controlledstudybyHertzbergetal.(2001)obupropionSRorsmokerswithposttraumatic

stressdisorder(PTSD)oundthatbupropionwas

welltoleratedandresultedinhigherratesosmoking

cessation(60percent)ascomparedtotheplacebo

(20 percent)



31/55

Also,inastudyoveteranswithpost-traumatic

stressdisorderwhoweresmokersMcFallandcolleagues(2005)oundthatsmokerswhoreceived

tobaccotreatmentintegratedwiththeirpsychiatric

carewerevetimesmorelikelythansmokerswho

receivedseparatetreatmenttoreportabstinence

romsmokingninemonthsaterthestudy.The

smokersreceivingtheintegratedtreatmentwere

morelikelytouseNRTandtoreceivemore

smokingcessationsessions.Additionally,cognitivebehavioraltherapytechniquesthatincorporate

cognitiverestructuringandexposuretherapytohelp

personslearntotolerateandbecomemore

comortablewithphysicalsensationsmaybehelpul

topersonswithanxietydisorders(Morissetteetal.,

2007).

Substance Use Disorders

Notsurprisingly,concurrentuseoalcoholand/or

otherdrugsisanegativepredictorosmoking

cessationoutcomesduringsmokingcessation

treatment(Hughes,1996).Long-termquitrateso

smokersinearlyrecoverromsubstanceuse

disorders(SUDs)arelow,atapproximately

12percent(Kalman,1998;Sussman,2002).

However,personswithapasthistoryoalcoholism

donodiersignicantlyromcontrolsubjectsin

tobaccotreatmentoutcomes(Hayordetal.,1999).

Thecombinedeectsoco-occurringsubstance

abuseandsmokingbehaviorsappeartosignicantly

infuencethehighratesosmokingcessation

treatmentailure(Weinbergeretal.,2006).Thereare

ewstudiesopharmacotherapeuticinterventionsor

smokinginsubstanceabusers,butsomeevidenceexistssuggestingthatnicotinereplacementand

behavioralapproachesareeective(Burlingetal.,

1996;Shoptawetal.,1996).Areviewotobacco

cessationstudiesbyel-Guebalyetal.(2002)ound

that quit rates ranged rom seven percent to 60

publishedcontrolledstudiesusingbupropionSRin

smokerswithco-occurringSUDs,althoughthesestudiesareinprogress(Weinbergeretal.2006).

Thetimingosmokingcessationtreatmentor

substanceabusersremainscontroversial

(Weinbergeretal,2006).Somestudiesoundthat

concurrenttreatmentorsmokingandotherdrugs

appearsnottobeassociatedwithincreaseduseo

alcoholorotherdrugs(Burlingetal.,2001;Kalmanetal.,2004,2001).Josephetal.(2004)oundthat

whilepatientsinalcoholtreatmentareinterestedin

smokingcessation,participateintreatment,and

demonstratesuccess,theydidnotshowanybenet

romconcurrenttobaccocessationtreatment.

Inact,Josephetal.oundthatdrinkingoutcomes

wereworsewithconcurrenttobaccotreatment,

suggestingthattobaccocessationinterventions

shouldbeprovidedtopatientsaterintensivealcohol

treatmenthasbeencompleted.



32/55

Notes

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


33/55

RelapsePrevention1 ComponentsoMinimalPractice

RelapsePrevention

2 ComponentsoPrescriptive

RelapsePrevention

R E L A P S E P R E V E N T I O N | 2 3


34/55

Most relapses occur soon ater a person quits

smoking, yet some people relapse months oreven years ater the quit date. Relapse prevention

programs can take the orm o either minimal (brie)

or prescriptive (more intensive) programs.

Components o Minimal Practice

Relapse PreventionTheseinterventionsshouldbepartoeveryencounter

withaconsumerwhohasquitrecently.Congratulateeveryex-tobaccouserundergoingrelapseprevention

onanysuccess.Stronglyencouragethemtoremain

abstinent.Whenencounteringarecentquitter,useopen-

endedquestionsdesignedtoinitiateconsumerproblem

solvingsuchasHowhasstoppingtobaccousehelped

you?Encouragetheconsumersactivediscussionothe

topicsbelow:

Thebenets,includingpotentialhealthbenetsthatthe

consumermayderiveromcessation.

Anysuccesstheconsumerhashadinquitting(duration

oabstinence,reductioninwithdrawal,etc.).

Theproblemsencounteredorthreatsanticipatedto

maintainingabstinence(e.g.,depression,weightgain,

alcoholandothertobaccousersinthehousehold).

Components o Prescriptive

Relapse PreventionDuringprescriptiverelapseprevention,aconsumermight

identiyaproblemthatthreatenshisorherabstinence.

Specicproblemslikelytobereportedbyconsumersand

potentialresponsesollow:

Lack o support or cessationScheduleollow-upvisitsortelephonecallswith

theconsumer.

Helptheconsumeridentiysourcesosupportwithin

hisorherenvironment.

Reertheconsumertoanappropriateorganizationthat

Relapseprevention

R E L A P S E P R E V E N T I O N | 2 4


35/55

Negative mood or depression

Isignicant,providecounseling,prescribeappropriatemedications,orreertheconsumerto

aspecialist.

Strong or prolonged withdrawal symptoms

Itheconsumerreportsprolongedcravingorother

withdrawalsymptoms,considerextendingtheuse

oanapprovedpharmacotherapyoradding/

combiningmedicationstoreducestrongwithdrawalsymptoms.

Weight gain

Recommendstartingorincreasingphysical

activity;discouragestrictdieting.

Reassuretheconsumerthatsomeweightgain

aterquittingiscommonandappearstobe

sel-limiting.

Emphasizetheimportanceoahealthydiet.

Maintaintheconsumeronpharmacotherapy

knowntodelayweightgain(e.g.,bupropionSR,

nicotine-replacementpharmacotherapies,

particularlynicotinegum).

Reerconsumertoaspecialistorprogram.

Flagging motivation / eeling deprived

Reassureconsumerthattheseeelings arecommon.

Recommendrewardingactivities.

Probetoensurethattheconsumerisnot

engagedinperiodictobaccouse

Emphasize that beginning to smoke (even a

pu) will increase urges and make quitting

more difcult.

Notes

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________


36/55

LocalandNationalTobaccoCessationResources

L O C A L a n d N A T I O N A L T O B A C C O C E S S A T I O N R E S O U R C E S | 2 5


37/55

STEPPHealthcareProviderWebSite

http://www.cohealthproviders.com

STEPP

http://www.steppcolorado.com

AmericanCancerSociety

http://www.cancer.org

AmericanHeartAssociationOColorado http://www.americanheart.org

AmericanLungAssociationoColorado

http://www.alacolo.org/

AmericanPublicHealthAssociation

http://www.apha.org/

CentersorDiseaseControlandPrevention

http://www.cdc.gov/tobacco

ColoradoClinicalGuidelinesCollaborative

http://www.coloradoguidelines.org/

ColoradoTobaccoEducationandPreventionAlliance

http://www.ctepa.org/

SocietyorResearchonNicotineandTobacco

http://www.srnt.org

SurgeonGeneral

http://www.surgeongeneral.gov/

Local andnational tobacco cessation resources

L O C A L a n d N A T I O N A L T O B A C C O C E S S A T I O N R E S O U R C E S | 2 6


38/55

Notes

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________


39/55

ToolkitReerences

T O O L K I T R E F E R E N C E S | 2 7


40/55

Addington J, el-Guebaly N, Campbell W, et al (1998).

Smoking cessation treatment for patients withschizophrenia.American Journal of Psychiatry, 155(7):

974976.

Alsene, K. M., Mahler, S. V., & de Wit, H. (2005).

Effects of d-amphetamine and smoking abstinence on

cue-induced cigarette craving. Experimental and Clinical

Psychopharmacology, 13, 209-218.

American Psychiatric Association (1996).

Practice guidelines for the treatment of patients with

nicotine dependence.American Journal of Psychiatry,

October Supplement, 1-31.

American Psychiatric Association Practice Guidelines

2006: Treatment of Patients with Substance Use

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LiteratureReview

L I T E R A T U R E R E V I E W | 3 3


47/55

Literature reviewIndividual Studies

Yr of

Pub

2001

1998

2006

1996

2001

2000

Author

Acton,G.,Prochaska,J.,

etal.

Addington,J.,

el-Guebaly,N.,

etal.

Baker,A.,

Richmond,R.,Haile,M.,

etal.

Borrelli,B.,

Niaura,R.,

etal.

Brown,R,,

Kahler,C.,

Niaura,R.,

etal

Combs,D.&

Advokat,C.

Article Name

Depressionandstagesochangeor

smokinginpsychiatric

outpatients

Smokingcessation

treatmentorpatients

withschizophrenia

Arandomized

controlledtrialoasmokingcessation

interventionamong

peoplewithapsychotic

disorder

DevelopmentoMDD

duringsmoking-

cessationtreatment

Cognitive-behavioral

treatmentor

depressioninsmoking

cessation

Antipsychotic

medicationand

smoking pre alence

Setting/

Contact

Type

Outpatientpsychiatric

research

center;

Survey

Outpatient

psychiatric

research

center;

Facetoace

Outpatient

mentalhealthclinics

orresearch

center;

Facetoace

Facetoace

Facetoace

Inpatient;

Facetoace

Volume # /

Issue #

AddictiveBehaviors,

26(5)

AmericanJ

oPsychiatry,

155(7)

AmericanJo

Psychiatry,163(111)

JoClinical

Psychiatry,

57(11)

JoConsulting

&Clinical

Psych,69

Schizophrenia

Research,

46(2 3)

Intervention

Correlationalstudy:205psychiatricoutpatients

completedmeasureso

depression(PRIME-MD

andBDI-II)

50schizophrenic

outpatientswere

dividedinto5groups

whometor7weekly

smokingcessation

programsessions

298regularsmokers

withapsychoticdisorderwererandomly

assignedtoatreatment

conditionconsistingo

8individualonehour

sessionsomotivational

interviewingand

cognitivebehavioral

therapyorcontrol

(treatmentasusual)

144non-depressedSs

tooktheBDIandthe

HamiltonRatingScale

orDepression;txwas

fuoxetine

Smokersw/MDD

randomizedtostandard

CBTsmokingcessation

txorsmokingcessationtx+CBTtreatmentor

depression

Schizophrenicpatients

whosmokedand

ere either recei ing

Results

PatientswhohadneversmokedshowedlowerratesoMDDthan

thosewhohadsmoked;patients

inearlystagesochangedidnot

showmoreMDDordepressive

symptoms,butshowedmore

negativethoughtsabout

abstinence;suggestbuilding

smokingcessationinterventions

basedonthetranstheoretical

modelochangeorusew/

psychiatricpops.

42%opatientshadstopped

smokingattheendothe

groupsessions,16%remained

abstinentat3mo,and12%at6

mo.;nochangesineitherposor

negsymptomsoschizophrenia.

Asignicantlyhigherproportion

osmokerswhocompletedalltreatmentsessionsstopped

smokingateachotheollow-

uptimesthancontrols(point

prevalenceratesat3months:

30%vs6%;6months:18.6%

vs4%;12months18.6%

vs4%).

5Ssmetthresholdcriteriaor

MDD.

SmokerwithrecurrentMDDand

heavysmokerswhoreceived

CBT-Dweresignicantlymore

likelytobeabstinentthaninstandardtreatment.

Clozapinewasassociated

withasignicantlylower

incidence o smoking than either



48/55

Yr of

Pub

1990

2002

1999

2005

2004

Author

Covey,L,

Glassman,A,

etal.

Covey,L,

Glassman,A,

etal.

Dalack,G.,

Becks,L.,

etal.

Evins,A.,

Cather,C.,

etal.

Evins,A.,

Rigotti,C.,

etal.

Article Name

Depressionand

depressivesymptoms

insmokingcessation

Arandomizedtrial

osertralineasa

cessationaidor

smokerswithahistory

omajordepression

Nicotinewithdrawland

psychiatricsymptoms

incigarettesmokers

withschizophrenia

Adouble-blind

placebo-controlled

trialobupropion

sustained-releaseor

smokingcessationin

schizophrenia

Two-yearollow-upo

asmokingcessation

trialinpatientswith

schizophrenia:

Setting/

Contact

Type

Facetoace

Facetoace

Outpatient

psychiatric

research

center;Facetoace

Recruited

rom

commu-

nitymental

health

centers;

Facetoace

Facetoace

Intervention

Investigationinto

resultsoabehaviorally

orientedsmoking

cessationprogram

showedsmokersw/

MDDhistoryhadlower

successrates

134smokerswith

historyoMDD

receivedSertraline

(n=68)ormatching

placebo(n=66)1wk

placebowashout,9wk

double-blind,placebo-

controlledtreatment

phaseollowedbya

9daytaperperiod,anda6mo.drugree

ollow-up;allreceived

intensiveindividual

cessationcounseling

during9clinicvisits

19outpatientsw/

schizophreniaor

schizoaective

disorder;1dayoadlibitumsmoking

ollowedby3days

oacutesmoking

abstinencewhile

wearing22mg/day

activeorplacebo

transdermalnicotine

patches,withareturn

to3daysosmoking

betweenpatch

conditions

bupropion-SRvs

placebo;andCBT

2yrollow-upto

bupropiontxw/CBT

Results

Firstweekrequencyand

intensityopsychological

symptoms,particularly

depressivemood,werehigher

amongsmokerswithpast

depression;interventions

shouldattempttoprevent

dysphoricsymptomsduring

acutewithdrawlperiodorMDD

smokers.

Sertralinetxproducedalower

totalwithdrawlsymptomscore

andlessirritability,anxiety,

craving,andrestlessnessthan

placebo;howevernosignicant

dierencebetweenthegroups.

Dyskinesiaswereoundtohave

decreasedduringabstinence

andplacebopatchtreatment,

butincreasedduringabstinenceandtheactivepatchconditions.

Ssinbupropiongrpweremore

likelytobeabstinentorthe

weekaterthequitdateand

attheendotheintervention;

Ssinthebupropiongrphada

higherrateo4-wkcontinuous

abstinence(wks8-12)anda

longerdurationoabstinence;

relapseishighollowingthe

discontinuation.

MoreSswereabstinentat

ollowupthanwereabstinentat

theendothetrial;decreased

smokingduringthetrialwas

Volume # /

Issue #

Comprehensive

Psychiatry,

31(4)

AmericanJ

oPsychiatry,

159(10)

Neuropsycho-

pharmacology,

21(2)

JoClinical

Psycho-

pharmacology,

25(3)

Clinical

Psychiatry,

65(3)



49/55

Yr of

Pub

1995

2002

2000

1997

1993

1991

2004

Author

George,T.,

Sernyak,M.,

etal.

George,T.,

Vessicchio,J.,

etal.

George,T.,

Ziedonis,D.,

etal.

Ginsburg,J.,

Klesges,R.,

etal.

Glassman,A.,

Covey,L.,

etal.

Greeman,M.&

McClellan,T.

Haas,A.,

Munoz,R.,

etal.

Article Name

Eectsoclozapine

onsmokingin

chronicschizophrenic

outpatients

Aplacebocontrolled

trialobupropionor

smokingcessationin

schizophrenia

Nicotinetransdermal

patchandatypical

antipsychotic

medicationsor

smokingcessationin

schizophrenia

Therelationship

betweenahistory

odepressionand

adherencetoa

multi-componentsmoking-cessation

program

Smokingcessation,

clonidine,and

vulnerabilitytonicotine

amongdependent

smokers

Negativeeectsoa

smoke-reeruleonan

inpatientpsychiatry

service

Infuencesomood,

depressionhistory,and

treatmentmodalityon

outcomesinsmokingcessation

Setting/

Contact

Type

Facetoace

Facetoace

Facetoace

Facetoace

Facetoace

Inpatient;

Facetoace

Facetoace

Intervention

29schizophrenic

outpatients;clozapine

txvsTYPneuroleptics

bupropion-SRvs

placebo

Ssw/schizoor

schizoatreatedw/

NTP&w/eitherATYP

orTYPantipsychotics;

GTotheAmer

LungAssnorGTor

smokersw/schizothat

emphasizedmotivationenhancement,relapse

prevention,social

skillstraining,and

psychoeducation

13wkCBG&random

assignmentto

nicotinegum,appetite

suppressantgum,or

placebogum

Clonidine

Smokingbanon

inpatientunitsata

VeteransAairsmedical

center

549Ss(28%w/history

oMDD);CBTvs.HE

Results

Therewasasigdecreasein

reporteddailyciguseater

clozapinetx.

Bupropion-SRincreased

smokingabstinencerates;pos

sympnotaected,negsymp

reduced;ATYPuseenhance

smokingcessationresponsestoBUP.

EectsoNTParemodestin

schizophrenicpatients;

nodierenceinGTprograms;

ATYPmaybesuperiortoTYP

incombinationw/NTP

orsmokingcessationin

schizophrenicpatients.

GroupCBTisaneective

smoking-cessationprogram

orwomenwithahistory

odepressionwhoarenot

currentlydepressed.

MDDpredicttxailure;an

increasedriskorpsychiatric

complicationsatersmoking

cessationwasapparentamong

smokerwithMDD,particularly

bipolar.

20-25%opatientswho

smokedhaddicultyadjusting

totherule,andsomepatients

experiencedmajordisruptionin

theirtx.

MDD-RSshadhigherrateso

abstinenceinCBTcompared

w/HE,evenwhenthe

contributionomoodandtheinteractionbetweenmoodand

anMDDxtxvariablewere

includedinthemodel.

Volume # /

Issue #

JoClinical

Psychiatry,

56(8)

Biological

Psychiatry,

52(1)

AmericanJ

oPsychiatry,

157(11)

Addictive

Behaviors,

22(6)

Clinical

Pharmacology

&Therapeutics,

54(6)

Hospital&

Community,

42(4)

JConsultClin

Psychol,72(4)



50/55

Yr of

Pub

1994

1998

1996

2005

Author

Hall,S.M.,

Reus,V.I.,

MunozR.F.,

etal

Hall,S.M.,

Reus,V.I.,

MunozR.F.,

etal

Hall,S.M.,

Reus,V.I.,MunozR.F.,

etal

Haug,N.A,

Hall,S.M.

Prochaska,J.J.

etal.

Article Name

Cognitive-behavioral

interventionincreases

abstinenceratesor

depressive-history

smokers

NortriptylineandCBT

inthetreatmento

cigarettesmoking

Moodmanagement

andnicotineguminsmokingtreatment:

Athera

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