Tobacco Cessation

and

Mental Health

Courtney Ward Arizona Department of Health Services

Bureau of Tobacco & Chronic Disease

Arizonans with Mental Illness

• Life expectancy lowers by 30 years, with

tobacco-related disease the biggest killer

• 75% of people with mental illness (approx.

100,000) use tobacco (5 x the Arizona rate)

• 33% of behavioral health providers use tobacco

(more than twice the Arizona rate)

• SAMSHA reports that over 50% of tobacco is

purchased by people with a mental illness

Facts

• Tobacco is the leading cause of death for patients previously treated for alcohol and other non-nicotine drugs of abuse

• Smoking exacerbates mental illness symptoms, HIV/AIDS symptoms, hepatitis C and other conditions

• Impact of exposure to secondhand smoke among nonsmoking clients and staff as well as family members (including children) is a very serious issue

Facts Cont’d

• The real bottom line is that with evidence

pouring in on the harm caused by

secondhand smoke, facilities are being

mandated to go smoke free; there will be

no choice

Patients Want to Quit

• Documented interest in quitting among clients

across all treatment modalities

• Standard treatment approaches work with these

patients (NRT plus behavioral counseling)

• Patients are already in a secure, supportive

environment ideal for nicotine cessation

Barriers to Success • Staff smoke in large numbers

• Tobacco use is not viewed as substance abuse

• Staff and clients smoking together is seen as informal counseling opportunity rather than a boundary or therapeutic issue

• Smoking viewed as a privilege and reward; programming is built around smoking breaks

• Tobacco is not seen as part of the treatment regimen

• Fear of behavioral management issues – nicotine withdrawal and blood levels

• Fear of medication toxicity – interaction of medications

What Are the Facts About

Smoking and Comorbidities?

Background

• 44% of cigarettes smoked in the U.S. are

consumed by individuals with a psychiatric or

substance abuse disorder

• Persons with mental illness are more than twice

as likely to smoke as others

• Roughly 60-95% of patients in addiction

treatment are tobacco dependent

• Of those individuals, roughly half smoke more

than 25 cigarettes per day

Background Cont’d • Cigarette smoking consistently appears highest

among people with psychotic disorders, but remains high also for depression, anxiety, substance abuse, and personality disorders

• An estimated 200,000 smokers with mental illness or addiction die each year due to smoking, a figure highly disproportionate to the number of those with mental disorders in the general population

Smoking and Depression

• Rates of smoking are estimated at 50-60%

in patients with a clinical diagnosis of

depression

• 25-40% of psychiatric patients seeking

smoking cessation treatment have a past

history of major depression or minor

dysthymic disorder

Smoking and Schizophrenia

• Patients with schizophrenia smoke three

times the rate of the general population

• Some studies show prevalence rates as

high as 90%

Smoking and Schizophrenia Cont’d

• Smokers with schizophrenia experience increased psychiatric symptoms, number of hospitalizations, and need for higher medication doses.

• The metabolism of tobacco (not nicotine) can dramatically affect psychiatric medication dosing requirements and blood levels by affecting the P450 liver cytochrome enzymes.

• Often smoking requires a doubling of medication dosage.

Anxiety Disorders and Tobacco • The presence of an anxiety disorder with or

without concurrent depression is associated with

an increased likelihood of smoking

• Smoking has been found to be a risk factor for

the onset of panic disorder; elevated smoking

rates are observed in patients with chronic panic

disorder

• Despite patients’ subjective reports that smoking

reduces anxiety, chronic nicotine use in animals

is related to increased anxiety

Smoking and Alcohol Dependence

• Smokers have a 2-3 times greater risk for

alcohol dependence than nonsmokers

• An estimated 80% of alcoholics currently

smoke

• More alcoholics die from smoking-related

diseases than from alcohol- related ones

• Both founders of Alcoholics Anonymous

died from their tobacco addictions

Smoking and Other Substance

Abuse

• Smoking rates are 2-3 times higher among

drug addicts than the general population

• Surveys have reported 85-98% smoking

prevalence rates in methadone

maintenance program patients

A Targeted Population

• As smoking prevalence declines, a greater

proportion of smokers are in this

population

• Tobacco companies actively target the

mentally ill and substance abusers

• This is proven through tobacco papers

(Project SCUM)

Secondhand Smoke

• Secondhand smoke contains 4000

chemicals, 50 of which are known

carcinogens, and 6 that negatively impact

childhood development and reduce fertility

in both sexes

• More non-smokers will die from exposure

to secondhand smoke than from any other

air pollutant

Secondhand Smoke Cont’d • Children of parents who smoke are at a higher

risk for developing chronic coughing, wheezing, and sputum production; middle ear infections; and asthma

• Infants are three times as likely to die from SIDS if their mothers smoked during and after pregnancy, and twice as likely if their mothers stop smoking during pregnancy but resume again following birth

What Can Be Done?

• Current situation is unacceptable

• Cessation will reduce, not increase,

suffering

• Secondhand smoke rules will force

change

• Starting now to help staff and patients quit

is vital

A Chance to Make a Real

Difference

• Highest prevalence and toughest issues in

this population

• Most to gain by breakthroughs

• Move toward mandates makes the issue

unavoidable

• If done right, this could be a tremendous

success story

What’s next?

Courtney Ward

Arizona Department of Health Services

Bureau of Tobacco & Chronic Disease

(602) 542-2075

wardc@azdhs.gov

Integrating Tobacco Free Living

into Behavioral Health Wellness

Tips and Tools for Development and Implementation

Peer-to-Peer Tobacco Recovery Program

This is a Critical Issue

What is killing the

majority of us is not

infectious disease,

but our chronic and

modifiable behaviors.

Programs Currently Implemented

Peer Support Whole Health

Appalachian Consulting Group, Inc.

Chronic Disease Self-Management Program

Arizona Living Well Institute

AshLine Partnership

ADHS/ Bureau of Tobacco and Chronic Disease

Peer-to-Peer Tobacco Recovery Program

Tobacco Dependence has

Two Parts

It is estimated that one person dies

from a tobacco-related illness

every 6 seconds

Understanding Tobacco Addiction

• Tobacco addiction is a chronic brain disease

• We need to treat the physical addiction, as well as the behavior

• The “Clinical Practice Guideline” - best strategy is a combination of

counseling and FDA approved cessation medications

• Addiction can be treated by using medications

• The behavior (habit) can be treated through programs focusing on

changing behavior such as peer support groups, counseling and

working on new behaviors

Burden of Tobacco

• 443,000 tobacco-related deaths in the U.S.

each year

• 6 million tobacco-related deaths worldwide

each year

• 8.6 million people living with tobacco-related

chronic illness

• 50,000 deaths each year in the U.S. due to

second-hand smoke exposure

It is estimated that one person dies

from a tobacco-related illness

every 6 seconds

Chemicals in Tobacco Products

Quitting Smoking Leads to a Longer and Healthier Life

It is estimated that one person dies

from a tobacco-related illness

every 6 seconds

Tobacco Cessation Strategies

Peer Groups and Quitlines

• Peer Support Whole Health

• Began in February on 2010

• Clinic Level, Peer Driven

• Chronic Disease Self-Management

• Trained Facilitators include PNO staff as well as Magellan Staff

• Behavioral Health lead Train the Trainer staff available in August

• 6 week program - groups have been well attended

Tobacco Cessation Strategies

Peer Groups and Quitlines

• Peer to Peer Tobacco Recovery Program

• 47 trained facilitators

• Weekly group with drop-in function

• Participants can join anytime

• AshLine

• Telephone counseling

• Web-based services

• Referrals for additional support

• May provide NRT or other medications

• May be available in multiple languages

Motivational Interviewing

• An intervention used to motivate people towards behavior change

• Originally a tool for recovery from addictions

• Now used in many different settings to help people change

unwanted behaviors

• The focus of this Motivational Intervention is to build the peer’s

motivation to change rather than to focus on the actual behavior

change

• Focus: Healthy Choices / Healthy Behaviors

It is estimated that one person dies

from a tobacco-related illness

every 6 seconds

Benefits of Quitting

A Wellness Philosophy

Leading a meaningful and fulfilling life through conscious and self-

directed behaviors, focused upon living at one’s fullest potential.

Quitting Tobacco and Mental Health

Courtney Ward, MPA

AZDHS BTCD

Tobacco Program Manager

What is ASHLine?

• Free help to quit tobacco – Coaching over the phone

– Self-paced quit program online

– Medication assistance

• Partner to healthcare systems and professionals – Referral program

– Technical assistance and training resources

What is ASHLine?

• Funding from the state tobacco tax through ADHS BTCD

• Housed at University of Arizona Mel and Enid Zuckerman College of Public Health

• Providing quitline services since 1995

Client services

Quit Coaches

• Client-directed, Outcome-informed approach (CDOI)

• Motivational Interviewing

• Medication assistance

Referral Outreach Team

• Contacts in Northern, Southern and Central Arizona

Client-directed, Outcome-informed

• Values the client-coach relationship

• Client determines focus, length, frequency of phone calls

– No script or curriculum

• Coaching can last anywhere from 3 to 6 months after the client quits

• The client can continue to work with the coach, even if they relapse

Motivational Interviewing

• Resolve ambivalence toward quitting

• Help develop problem solving skills

– Create a quit plan

– Withstand cravings

• Work to develop social support network to maintain tobacco free lifestyle

Medication assistance

• Two weeks of nicotine patch, gum, or lozenge available to all enrolled ASHLine clients

– Mailed directly to residence

• EXCEPT – Title XIX AHCCCS beneficiaries who can receive 12 weeks of any FDA-approved quit tobacco medication on prescription from their primary care provider

The role you play in quitting tobacco

• Tobacco use is cited as the chief avoidable cause of death in the US

• Smokers cite physician advice to quit as an important motivator

• Healthcare systems should craft policy that makes tobacco use treatment an integral part of healthcare

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.

Passive Referral vs. Proactive Referral

QuitFax referral form

Passive Referral vs. Proactive Referral

Passive Referral vs. Proactive Referral

Online Status Report

Online Follow-Up Report

WebQuit online referral

Electronic Health Records

ASHLine referral reports

• Confirmation

– Within 24 hours

• Status report

– Within 10 days

– First call within 24 hours

– Up to 5 attempts to contact over 10 days

• Monthly newsletter

Can be received by fax, email, or both!

ASHLine referral program

Three ways to refer

• QuitFax referral form

• WebQuit online referral

• Electronic Health Records

How To Implement

• Ask every client about their tobacco use at every visit: “How much tobacco have you used since our last visit?”

• Advise that “quitting smoking” is the very best thing you can do for your health”

• Refer to the Arizona Smokers’ Helpline by using the QuitFax referral program

Online

Material

Requests

Contact Information

Courtney Ward, MPA

wardc@azdhs.gov

602-542-2075

Karen Akin, MPA

karenakin@email.arizona.edu

800-556-6222 ext.543