Copyright © The Regents of the University of California.

Evidence-Based Tobacco Use Treatments
17/FEBRUARY 2012

Copyright © 1999-2011 The Regents of the University of California.
All rights reserved. Portions of this program were adapted, with permission, from the Rx for Change: Clinician-Assisted Tobacco Cessation program VA Tobacco Use Cessation Program Curriculum Committee: Jeannie Beckham, Ph.D. Timothy Carmody, Ph.D., Timothy Chen, Ph.D., Dana Christofferson, Ph.D., Judith Cooney, Ph.D., Margaret Dundon, Ph.D., Steven Fu, MD, MSCE, Kim Hamlett-Berry, Ph.D., Miles McFall, Ph.D. 1

OVERVIEW—First Hour Epidemiology and Burden of Tobacco Use
Evidence-based Treatment: Clinical Practice Guidelines Behavioral Interventions Pharmacotherapy

Tobacco Use: The Problem
Tobacco use is the #1 cause of preventable death and disease in the U.S. Tobacco use causes 443,000 deaths each year in the U.S. 50% of people who smoke die prematurely Nicotine is the most addictive substance on the planet Tobacco use is a chronic, relapsing condition

Comparative Causes Of Annual Deaths in the United States
Individuals with mental illness or substance use disorders Number of Deaths (thousands) Tobacco is the leading preventable cause of death in the US accounting for 440,000 deaths each year, more than AIDS, obesity, alcohol, motor vehicle accidents, homicide, drug induced and suicides, all combined. Based on the Lasser et al., 2000 study, 40.6% of smokers have current mental illness. If 440,000 deaths annually due to smoking, an estimated 178,640 are among individuals with current mental illness. Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smoking and mental illness: A population-based prevalence study. JAMA. Nov ;284(20): AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced Source: CDC

2011 Current Smokers in VA

Trends in Adult Smoking, By Sex U.S. 1955–2010
Trends in current cigarette smoking among persons aged 18 or older 19.4% of adults are current smokers Male 70% of smokers want to quit This graph demonstrates trends in smoking among adults in the U.S. between 1955 and 2007 (CDC, 1999, 2007). 2007 data are provisional, obtained from Since 1990, the smoking prevalence among men and women has experienced only a slight decline, compared to previous decades, highlighting a need for enhanced tobacco control efforts. The 2007 National Health Interview Survey (NHIS) data indicate that approximately 43.4 million adults (19.4% of the U.S. adult population) are current smokers1. Of these, 77.8% smoke every day and 22.2% smoke some days. More men (21.9%) than women (17.1%) are current smokers. An estimated 70% of all smokers want to quit completely (CDC, 2002), and in 2006, 44.2% of current smokers reported that they stopped smoking for more than 1 day during the past 12 months because they were trying to quit (CDC, 2007). In 2006, an estimated 45.7 million adults were former smokers,2 representing 50.2% of persons who had ever smoked (CDC, 2007). ♪ Note to instructor(s): Cessation statistics vary depending on factors such as the duration of follow-up, definitions of abstinence, and whether reports of cessation were biologically confirmed. According to the CDC (2002), 4.7% of smokers who had smoked every day or some days during the past year had quit and were able to maintain abstinence for 3–12 months in 2000. 1Current smokers: persons who reported having smoked 100 or more cigarettes during their lifetime and who smoked every day or some days at the time of the assessment. 2Former smokers: persons who reported having smoked 100 or more cigarettes during their lifetime but currently did not smoke. Centers for Disease Control and Prevention (CDC). (1999). Achievements in public health, 1900–1999: Tobacco use—United States, 1900–1999. MMWR 48:986–993. Centers for Disease Control and Prevention. (2002). Cigarette smoking among adults—United States, MMWR 51:642–645. Centers for Disease Control and Prevention. (2007). Tobacco use among adults—United States, MMWR 56:1157–1161. Centers for Disease Control and Prevention. (2008). Tobacco use among adults—United States, MMWR 57:1221–1226. Percent 21.4% Female 17.2% Year Graph provided by the Centers for Disease Control and Prevention Current Population Survey; 1965–2010 NHIS. Estimates since 1992 include some-day smoking. 6

Smoking as a Health Disparity Issue
Smoking is a health disparity issue, with higher rates of smoking among those with lower income and educational levels, as well as populations such as American Indians, Alaskan native populations, and populations with co-morbid psychiatric or substance use disorders. These are the same populations that are less likely to have access to evidence-based treatment or have smoke-free workplaces. Almost 1 out of every 2 cigarettes sold is sold to an adult with psychiatric illness. A 2009 study of an urban public hospital population found ‘extraordinarily high’ rates of smoking and high levels of secondhand smoke exposures, as assessed through cotinine levels upon admission. Levels were similar to national levels in the 1950s. (Benowitz et al., 2009)

Smoking Rates Vary by Race and Socioeconomic Status
National Health Interview Survey (NHIS) 2010 of adults aged 18 and older in U.S. AI/AN = American Indian/ Alaskan Native Brian King, PhD, Shanta Dube, PhD, Rachel Kaufmann, PhD, Lauren Shaw, MS , Terry Pechacek, PhD, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Vital Signs: Current Cigarette Smoking Among Adults Aged ≥18 Years — United States, 2005–2010 MMWR / September 9, 2011 / Vol. 60 / No. 35 p King et al., MMWR, 2011

Education Level Influences Smoking Rates
Rates of current cigarette smoking decrease with increasing education Note: Lower rate of smoking for those with less than HS diploma probably reflects ethnic differences in smoking rates; e.g., immigrants from central and south American countries with lower smoking rates, particularly among women. National Health Interview Survey (NHIS) 2010 of adults aged 18 and older in U.S. Brian King, PhD, Shanta Dube, PhD, Rachel Kaufmann, PhD, Lauren Shaw, MS , Terry Pechacek, PhD, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Vital Signs: Current Cigarette Smoking Among Adults Aged ≥18 Years — United States, 2005–2010 MMWR / September 9, 2011 / Vol. 60 / No. 35 p King et al., MMWR, 2011

Decreasing Rates of Tobacco Use: The Solution
Effective treatments exist that can significantly increase rates of long-term abstinence and are supported by the 2008 United States Public Health Services Update of Clinical Practice Guidelines on the Clinical Treatment of Tobacco Use and Dependence (USPHS CPG). Policies that reduce smoking prevalence: Increasing tobacco taxes Smoke-free workplace, restaurant, and bar laws Changes in cultural norms around smoking and tobacco use A summary of the 2008 Public Health Guidelines were provided in the Pre-symposium materials. Use of tobacco cessation medications can more than double success rates for quitting tobacco.

De-normalization of Tobacco Use
Many states have banned smoking in workplaces, bars, and restaurants Some cities and states are also contemplating laws regulating smoking in public housing and apartment buildings, as well as outdoor spaces With fewer places to smoke, smokers have become increasingly marginalized As rates of tobacco use have declined, those who use tobacco are disproportionately less educated and of a lower socioeconomic status Image of a smoker has changed from “handsome, successful” to “asocial, irresponsible, and self-destructive” This de-normalization has helped with tobacco control efforts and to induce smokers to quit, however some worry that this tactic has resulted in the stigmatization of smokers - is this the solution, or part of the problem for MH populations? Does this increase their stigmatization? Bayer & Stuber, 2006

Quitting: Health Benefits
Time Since Quit Date Circulation improves, walking becomes easier Lung function increases up to 30% Lung cilia regain normal function Ability to clear lungs of mucus increases Coughing, fatigue, shortness of breath decrease 2 wks - 3 mos 1 - 9 mos The 1990 Surgeon General’s Report on the health benefits of smoking cessation outlines the numerous and substantial health benefits incurred when patients quit smoking (USDHHS, 1990). Health benefits realized 2 weeks to 3 months after quitting include the following: circulation improves, walking becomes easier, and lung function increases up to 30%. One to nine months later, lung ciliary function is restored. This improved mucociliary clearance greatly decreases the chance of infection because the lung environment is no longer as conducive to bacterial growth. Consequently, coughing, sinus congestion, fatigue, and shortness of breath decrease. In some patients, coughing might actually increase shortly after quitting. This is because the cilia in pulmonary epithelial cells are functioning “normally” and are more effectively clearing the residual tars and other accumulated components of tobacco smoke. One year later, excess risk of coronary heart disease is decreased to half that of a smoker. After 5 to 15 years, stroke risk is reduced to a rate similar to that of people who have never smoked. Ten years after quitting, an individual’s chance of dying of lung cancer is approximately half that of continuing smokers. Additionally, the chance of getting mouth, throat, esophagus, bladder, kidney, or pancreatic cancer is decreased. Finally, 15 years after quitting, an individual’s risk of coronary heart disease is reduced to a rate that is similar to that of people who have never smoked. Thus, the benefits of quitting are significant. It is never too late to quit to incur many of the benefits of quitting. The next slide depicts the advantage of quitting earlier in life, as opposed to later. American Cancer Society. American Lung Association. U.S. Department of Health and Human Services. The Health Benefits of Smoking Cessation. A Report of the Surgeon General. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention and Health Promotion, Office on Smoking and Health. DSSH Publication No. (CDC) , 1990. Excess risk of CHD decreases to half that of a continuing smoker 1 yr Risk of stroke is reduced to that of people who have never smoked 5 yrs Lung cancer death rate drops to half that of a continuing smoker Risk of cancer of mouth, throat, esophagus, bladder, kidney, pancreas decrease 10 yrs Risk of CHD is similar to that of people who have never smoked 15+ yrs

Quitting Increases Life Expectancy
This prospective study by Doll and colleagues of 34,439 male doctors in the United Kingdom followed cause-specific mortality by smoking habit for 50 years (1951 to 2001) and concluded that quitting smoking, even later in life, improves life expectancy. Those who quit at age 40 gained about 9 years of life expectancy. A smoker who quit at age 50 gained about 6 years of life expectancy. Smokers who quit at age 60 years gained at least 3 years of life expectancy. As it appears here, the sooner a smoker succeeds with smoking cessation, the better the impact on their life expectancy. Doll R et al., BMJ, : Doll et al., BMJ, 2004 Reference Doll R, Peto R, Boreham J, et al. Mortality in relation to smoking: 50 years' observations on male British doctors. BMJ. 2004;328:1519–1527.

Tobacco Dependence is a Chronic Disease
Physiological Behavioral The addiction to nicotine Medications for cessation The habit of using tobacco Behavior change program Treatment should address the physiological and the behavioral aspects of dependence

Quit Attempts & Treatment Utilization
70% of smokers report wanting to quit About half of all people who smoke try to quit each year Only 3-5% of quit attempts are successful Although effective treatments exist, about two thirds of quit attempts do not use any evidence-based treatment Less than 1/3 of people who quit use medication Less than 10% of people who quit use behavioral counseling Less than 6% of people use both medication and behavioral counseling during their quit attempt Shiffman et al., Am J Prev Med, 2008 Shiffman, Am J Prev Med, 2010

Evidence-Based Smoking Cessation Treatments Exist: 2008 Clinical Practice Guidelines
2008 Update: Treating Tobacco Use and Dependence, U.S. Department of Health and Human Services – Public Health Service (PHS) In 2009, the 2008 Update of the PHS Guidelines was adopted as the VA/DoD Clinical Practice Guideline for the Management of Tobacco Use. The Clinical Practice Guidelines describe effective evidence-based smoking cessation treatments.

CPG 2008: Main Findings on Treating Tobacco Use
Every smoker should be screened for tobacco use and willingness to quit at each session All smokers should be offered pharmacotherapy to assist in quitting Brief advice given by MD and non-MD clinicians effective in increasing quit rates Dose Response Relationship between counseling intensity and effectiveness While more intensive counseling is more efficacious, even brief counseling (2 minutes) can double quit rate The main findings on treating tobacco use are summarized in this slide.

Estimated Odds Ratio (95% C.I.) Estimated Abstinence Rate (95% C.I.)
Behavioral Counseling: Intensity/Session Length CPG Table 6.8: Effectiveness of and estimated abstinence rates for various intensity levels of session length (n=43 studies) Level of Contact Number of Arms Estimated Odds Ratio (95% C.I.) Estimated Abstinence Rate (95% C.I.) No Contact 30 1.0 10.9 Minimal Counseling (< 3 minutes) 19 1.3 (1.01—1.6) 13.4 (10.9—16.1) Low-Intensity Counseling (3-10 minutes) 16 1.6 (1.2—2.0) 16.0 (12.8—19.2) Higher Intensity Counseling (> 10 minutes) 55 2.3 (2.0—2.7) 22.1 (19.4—24.7) Recommendation: Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates. Every tobacco user should be offered at least a minimal intervention, whether or not s/he is referred to an intensive intervention. Strength of Evidence = A Recommendation: There is a strong dose-response relation between session length of person-to-person contact and successful treatment outcomes. Intensive interventions are more effective than less intensive interventions and should be used whenever possible. Strength of Evidence = A. Minimal interventions are effective and interventions lasting longer are more effective than shorter sessions.

Behavioral Counseling: Number of Sessions CPG Table 6.10: Effectiveness of and estimated abstinence rates for various intensity levels of session length (n=46 studies) Number of Sessions Number of Arms Estimated Odds Ratio (95% C.I.) Estimated Abstinence Rate (95% C.I.) 0-1 Session 43 1.0 12.4 2-3 Sessions 17 1.4 (1.1—1.7) 16.3 (13.7—19.0) 4-8 Sessions 23 1.9 (1.6—2.2) 20.9 (18.1—23.6) >8 Sessions 51 2.3 (2.1—3.0) 24.7 (21.0—28.4) Behavioral counseling delivered for four or more sessions appears to be especially effective in increasing abstinence rates. Recommendation: Person-to-person treatment delivered for four or more sessions appears especially effective in increasing abstinence rates. Therefore clinicians should strive to meet four or more times with individuals quitting tobacco use. Strength of Evidence = A.

Behavioral Counseling Formats CPG Table 6.13 : Effectiveness of and estimated abstinence rates for various types of formats (n=58 studies) Counseling Format Number of Arms Estimated Odds Ratio (95% C.I.) Estimated Abstinence Rate (95% C.I.) No Format 20 1.0 10.8 Self-help 93 1.2 (1.02—1.3) 12.3 (10.9—13.6) Proactive telephone counseling 26 1.2 (1.1—1.4) 13.1 (11.4—14.8) Group counseling 52 1.3 (1.1—1.6) 13.9 (11.6—16.1) Individual counseling 67 1.7 (1.4—2.0) 16.8 (14.7—19.1) Meta analyses show that group and individual counseling are the most effective formats for counseling. Self help materials were found to be marginally effective. Proactive telephone counseling – where there is person to person counseling via phone, not just smokers calling in, but providers calling smokers proactively to assess smoking status and assist with relapse prevention planning, are helpful. One method of proactive telephone counseling, Quitlines, was further assessed in guidelines Recommendation: Proactive telephone counseling, group counseling, and individual counseling formats are effective and should be used in smoking cessation interventions. Strength of Evidence = A

Effectiveness of intervention by type of clinician CPG Table 6.11: Effectiveness of and estimated abstinence rates for interventions delivered by different types of clinicians (n=29 studies) Type of Clinician Number of Arms Estimated Odds Ratio (95% C.I.) Estimated Abstinence Rate (95% C.I.) No clinician 16 1.0 10.2 Self-help 47 1.1 (0.9—1.3) 10.9 (9.1—12.7) Nonphysician clinician 39 1.7 (1.3—2.1) 15.8 (12.8—18.8) Physician clinician 11 2.2 (1.5—3.2) 19.9 (13.7—26.2) Recommendation: Treatment delivered by a variety of clinician types increases abstinence rates. Therefore, all clinicians should provide smoking cessation interventions. Strength of Evidence = A

CPG 2008: The "5 A" model Helping smokers through the process of quitting
ASK Do you currently use tobacco? ADVISE Use clear, strong, personalized messages: I think it is important that you quit smoking. I can help. Quitting smoking is one of the most important things you can do to protect your health. Smoking interferes with your psych medications. Stopping smoking can improve your mood. ASSESS Are you willing to give quitting a try in the next 30 days? ASSIST Help patients with quitting – provide counseling, increase motivation to quit ARRANGE Set up follow-up sessions and/or attendance at smoking cessation clinic Here is an overview of the “5A” model for helping smokers through the process of quitting as presented in CPG 2008.

Stages of Quitting For most patients, quitting is a cyclical process, and their readiness to quit (or stay quit) will change over time. Former tobacco user > 6 months Not thinking about it This diagram emphasizes that behavior change is a process. Over time, patients often cycle into and out of the different stages. They might quit for a while, then return to tobacco use before they quit again for good. This movement between the stages is normal and is to be expected, particularly for an addictive behavior that patients know they need to stop but might not have the time, energy, or will to stop at the present time. For this reason, it is important to determine the patient’s readiness to commit to quitting at each contact. Do not assume that patients who inquire about quitting are ready to quit. Commonly, they are just thinking about it and gathering information. Similarly, do not assume that a patient who asks for a prescription for bupropion, varenicline, or nicotine replacement therapy or who presents at a pharmacy to purchase these medications is ready to quit. Learning about the different stages of readiness to quit will help clinicians gain a better understanding of why it is important to think of behavior change as a process, not an event. For most people, the process of quitting is characterized by a series of quit attempts and subsequent relapses—on average, former smokers report 10.8 quit attempts over a period of 18.6 years before quitting for good (Hazelden Foundation, 1998). Hazelden Foundation. (1998). Survey on current and former smokers—1998. Center City, MN: Hazelden Foundation. Not ready to quit Relapse Thinking about it, not ready Recent quitter Assess readiness to quit (or to stay quit) at each patient contact. Ready to quit

When a Patient is Ready to Quit:
ASSESS and ASSIST (5A’s) Assess: tobacco use history Discuss: key issues /barriers Facilitate: quitting process Practical counseling Problem solving Coping skills training Social support delivered as part of treatment Three key elements of tobacco cessation counseling: Assess tobacco use history Discuss key issues or barriers Facilitate the quitting process, including practical counseling (problem solving/skills training) and social support (provider, class participants, Quit Lines) delivered as part of treatment (Fiore et al., 2008) Fiore MC, Jaén CR, Baker TB, et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service.

When a Patient is Ready to Quit: ASSESS Tobacco Use History
Praise the patient’s readiness Assess tobacco use history Current use: type(s) of tobacco, amount Past use: duration, recent changes Past quit attempts: Number, date, length Methods used, compliance, duration Reasons for relapse This stage represents a window of opportunity for helping a patient make a quit attempt. Clinicians should do the following prior to making treatment recommendations: Praise the patient’s readiness to quit. Assess tobacco use history, including current use, past use, and history of quit attempts: Current use of tobacco: What types of tobacco are used? How much? Past use of tobacco: How long has the patient been using tobacco? Has the patient changed his or her level of tobacco use recently? Past quit attempts: How many quit attempts has the patient made, how long was he or she off of tobacco, and when was the last quit attempt? What methods were used? What worked? What didn’t work? If medications were used, how were they used? What factors contributed to relapse (e.g., medication noncompliance, situational factors)? Identifying reasons for relapse can provide important information for an upcoming quit attempt.

When a Patient is Ready to Quit: DISCUSS Key Issues and Barriers
Reasons/motivation to quit What would be good about quitting? Common reasons include: Health concerns Social concerns Financial concerns Confidence in ability to quit How confident are you about quitting? Many patients may lack confidence due to prior failed attempts To increase patient confidence, psychologists can: Provide additional support Work with patient to design a treatment plan Emphasize that this time will be different because the patient will be more prepared Key issues to address include the following: Discuss reasons and motivations for wanting to quit. Ask the patient to think about why it is important, to him or her, to adopt a tobacco-free lifestyle. What are the patient’s motivations for wanting to quit? Discuss whether the patient has concerns about the effects of second-hand smoke on others. How confident is the patient in his or her ability to quit? Ideally, the patient will be highly confident, but many will lack confidence because of previously failed attempts. By providing additional support and working with the patient in designing the treatment plan, a clinician can infuse confidence into the patient. It will be “different,” this time, because the patient will be more prepared.

Identify triggers BEFORE quitting Triggers for tobacco use What situations lead to temptations to use tobacco? What led to relapse in the past? Examples of routines/situations associated with tobacco use: When drinking coffee After meals or after sex While driving in the car During breaks at work When bored or stressed While on the telephone While watching television While with specific friends or family members who use tobacco While at a bar with friends Discuss specific triggers for tobacco use. Triggers might include negative affect, being around other smokers, meal times, alcohol or coffee consumption, cravings for tobacco, time pressures, or other situations such as celebrating with others. Triggers should be identified prior to quitting, while the patient is still smoking “normally.” Encourage patients to think about the times and places where they smoke or use tobacco, each time they do so. This provides important insight into a person’s tobacco use behavior, including the circumstances that underlie the need or desire for tobacco. Having a clear understanding of the behavior will help a person to be more effective when attempting to change it. Determine whether there are certain routines or situations that the patient associates with tobacco use (e.g., when drinking coffee, while driving in the car, while bored or stressed, while watching television, while at a bar with friends, after meals or after sex, during breaks at work, while on the telephone, or while with specific friends or family members who smoke).

When a Patient is Ready to Quit: Key Issues and Barriers for Women
Different stressors and barriers to quitting compared to men Greater likelihood of depression Weight control concerns Estrogen may contribute to higher metabolism of nicotine compared to men, making nicotine replacement therapies less effective Different motives for smoking (e.g., socialization) More educated women may be more likely to smoke than less educated women Single women are more likely to smoke than married women Base on limited studies, the 2008 Clinical practice guidelines reports that female smokers may have different stressors and barriers Women smokers may have: Greater likelihood of depression Weight control concerns Higher metabolism of NRTs (possibly estrogen mediated) so NRTs may be less effective More need for socialization More educated  may be more likely to smoke Single people are more likely to smoke **Note these are from limited research, so should be studied further*** Fiore et al. Treating Tobacco Use and Dependence: 2008 Update

Concerns about withdrawal symptoms Chest tightness Stomach pain, constipation, gas Cough, dry throat Cravings Depressed mood Fatigue Hunger Insomnia Irritability Most do not last more than 2-4 weeks after quitting Cravings can last longer, up to several months or years Often can be ameliorated with cognitive or behavioral coping strategies Most symptoms manifest within the first 1–2 days, peak within the first week, and subside within 2–4 weeks. Chest Tightness (Tension created by body’s need for nicotine) – Relaxation techniques, NRTs\ Stomach pain, constipation, gas (Decrease of intestinal movement) – Drink fluids, fruits and vegetables Cough, dry throat, nasal drip (Body getting rid of mucus) – Drink fluids, avoid stress Craving (Nicotine withdrawal/habit) – DEADS Strategy (Delay, Escape, Avoid, Distract, Substitute) Depressed Mood (Normal process for a short period) – Increase pleasurable activities, get support from family/friends, discuss with provider Difficulty concentrating (Body needs time to adjust to not have constant nicotine stimulation) –Avoid stress, plan workload accordingly Dizziness (Body is getting extra oxygen) – Be caution the first few days Fatigue (Lack of stimulation of nicotine) – Take naps, Do not push yourself, NRTs might help Hunger (Cravings for cigarette can be mistaken for hunger) - Drink lots of water, eat low calorie snacks Insomnia (Nicotine affects brain wave function and sleep patterns) – Limit caffeine (reduce by 50%), relaxation techniques Irritability (Body’s craving for nicotine) – Exercise, relaxation techniques, take hot bath

When a Patient is Ready to Quit: FACILITATE the Quitting Process
Discuss methods for quitting Discuss pros and cons of available methods Pharmacotherapy: A treatment, not a crutch! Importance of behavioral counseling Set a quit date Discuss coping strategies Cognitive coping strategies Focus on retraining the way a patient thinks Behavioral coping strategies Involve specific actions to reduce risk for relapse In facilitating the quitting process, clinicians should Discuss the pros and cons of different methods for quitting. It is important to elicit the patient’s point of view—each patient will have his or her own perceptions of the different methods. Encourage use of pharmacotherapy in addition to behavioral counseling. Many patients will feel that pharmacotherapy is a “crutch”—these patients should be advised that tobacco use is a chronic condition that alters brain chemistry and that, when feasible and not contraindicated, pharmacotherapy should be used because it increases the chances of quitting. It should be viewed as a treatment, not a crutch. Help the patient set a quit date. Ideally, this will be within the next two weeks (Fiore et al., 2008). Recommend the Tobacco Use Log, if appropriate. This tool helps patients to identify moods, activities, or situations that trigger the desire to smoke or use other forms of tobacco. Triggers for tobacco use might include negative affect, being around other smokers, meal times, alcohol or coffee consumption, cravings for tobacco, stress, time pressures, or other situations such as celebrating with others. Triggers should be identified prior to quitting, while the patient is still smoking “normally.” Information gathered in the log can be used to develop coping strategies to overcome the temptation to use tobacco. ♪ Note to instructor(s): Have audience refer to the Tobacco Use Log handout. The Tobacco Use Log (ancillary handout A5 TOB USE LOG.pdf) is most appropriate for patients who are ready to quit, but it can be used with any patient who wants to learn more about his or her tobacco use behavior. This exercise provides important insight into the circumstances that underlie the need or desire for tobacco. Having a clear understanding of the behavior will help a person to be more effective when attempting to change it. Fiore MC, Jaén CR, Baker TB, et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. Tobacco Use Log adapted from The Wrap Sheet and the Daily Cigarette Count (Wrap Sheet). In: The Washington State Pharmacists Association. (1997). “Smoking Cessation Training: Pharmacists Becoming Smoking Cessation Counselors,” pp. 3, 25.

Cognitive Coping Strategies Retrain the way a patient thinks. Many panic because they are thinking about tobacco after they quit, which can lead to relapse. Cognitive coping strategies help patients learn to recognize that thinking about a cigarette does not mean they need to have one. Review commitment to quit I want to be a nonsmoker, and the temptation will pass. Distractive thinking Positive self-talk Remind of previous difficult situations where he/she successfully avoided tobacco use Relaxation through imagery Mental rehearsal and visualization Cognitive strategies focus on retraining the way a patient thinks. Many quitters panic because they are thinking about tobacco after they quit, and this leads to relapse. Thinking about cigarettes (or other forms of tobacco) is normal. The trick is not to dwell on the thought. As tobacco users move toward sustained abstinence, they learn to recognize that thinking about a cigarette doesn’t mean they need to have one. Some examples of cognitive strategies include the following: Review of one’s commitment to quitting can help, including reminding oneself that cravings and temptations are temporary and will pass. Sometimes it helps a patient to announce, either silently or out loud, “I want to be a nonsmoker, and the temptation will pass.” Or each morning, to look in the mirror and say, “I am proud that I made it through another day without tobacco!” Deliberate, distractive thinking can help the patient move current thought processes to issues other than craving or temptation to use tobacco. Positive self-talks, or “pep-talks,” involve saying things such as, “I can do this,” or reminding oneself of previous difficult situations in which tobacco use was avoided successfully. Relaxation through imagery helps the patient to center the mind on positive, relaxing thoughts. This can help to ease the anxiety, stress, and negative moods that may trigger tobacco use. Mental rehearsal and visualization involves envisioning situations that might arise and how best to handle them. This method is commonly used by athletes prior to a game. For example, a goalie might envision (or enact, during pregame warmups) how to block different types of shots or plays from opposing players. In the case of smoking, a person might envision what would happen if he or she were offered a cigarette by a friend—he or she would mentally craft and rehearse a response and perhaps even practice it by saying it out loud.

Behavioral Coping Strategies Specific actions for dealing with the effects of quitting and reducing the risk for relapse. Some techniques may work better for some than others. The patient’s reasons for and times they use tobacco may help to determine which strategies to use. Control your environment Tobacco-free home and workplace Remove cues to tobacco use; actively avoid trigger situations Modify behaviors that you associate with tobacco: when, what, where, how, with whom Substitutes for smoking Water, sugar-free chewing gum or hard candies (oral substitutes) Take a walk, diaphragmatic breathing, self-massage Actively work to reduce stress, obtain social support, and alleviate withdrawal symptoms Behavioral strategies involved specific actions for coping with the effects of quitting and reducing risk for relapse. The effectiveness of these strategies may be patient specific, meaning that one technique will work better for some patients than for others. To determine which strategies work best for a specific patient, a clinician must understand the patient’s reasons for tobacco use and routines or situations with which tobacco use is associated. General approaches include enhanced control of the environment. Tobacco-free environments (e.g., home and workplace) can increase chances of success (e.g., Bauer et al., 2005; Chapman et al., 1999; Eriksen & Cerak, 2008)—nationally, the effects of transitioning all workplaces to smoke-free environments would yield an estimated 4.5% decrease in the overall prevalence of smoking (Fichtenberg & Glantz, 2002). Patients should be advised to remove cues for tobacco use, modify behaviors associated with tobacco use, and actively avoid specific situations in which tobacco use is likely to occur. Oral substitutes for tobacco use include drinking water; chewing sugar-free gum; or sucking on hard, sugar-free candies. Taking walks helps to change the tobacco user’s environment and also increases circulation and oxygenation while burning calories. Deep breathing can have a relaxing effect, and research suggests that self-massage might reduce cravings (Hernandez-Reif et al., 1999). Withdrawal symptoms are inevitable, especially with patients who are heavy users of tobacco products. It is important that clinicians educate their patients so that they know what to expect, how to alleviate specific symptoms, and how long to expect the symptoms to last. ♪ Note to instructor(s): Specific behavioral strategies for common cues or causes of relapse (stress, alcohol, other tobacco users, oral gratification needs, automatic smoking routines, postcessation weight gain, cravings for tobacco) are presented in the Coping with Quitting: Cognitive and Behavioral Strategies handout. Bauer JE, Hyland A, Li Q, Steger C, Cummings KM. (2005). A longitudinal assessment of the impact of smoke-free worksite policies on tobacco use. Am J Public Health 95:1024–1029. Chapman S, Borland R, Scollo M, Bronson RC, Dominello A, Woodward S. (1999). The impact of smoke-free workplaces on declining cigarette consumption in Australia and the United States. Am J Public Health 89:1018–1023. Ericksen MP, Cerak RL. The diffusion and impact of clean indoor air laws. (2008). Annu Rev Public Health 29:171–185. Fichtenberg CM, Glantz SA. (2002). Effect of smoke-free workplaces on smoking behavior: systematic review. BMJ 325:188–191. Hernandez-Reif M, Field T, Hart S. (1999). Smoking cravings are reduced by self-massage. Prev Med 28:28–32.

DEADS Strategy DELAY Urge will fade after 5-10 minutes. ESCAPE Remove yourself from the situation or trigger which led to the urge. AVOID Avoiding situations and triggers that are associated with smoking. DISTRACT Get busy with an activity to keep your mind off the urge. SUBSTITUTE Use healthy snacks or objects such as straw or toothpick during an urge. Delay: The most important thing to remember is that an urge will go away if you just give it time. Waiting out an urge, especially if you begin to do something else, is easier than you may expect. Believe it or not, the urge will fade after 5 to 10 minutes, even if you do not smoke. It also helps if you have a positive attitude about the urge disappearing. Think "this won't last, the urge will go away," or "I would like a cigarette, but I'm not going to have one, because I don't need one." Escape: Another technique for dealing with an urge is to remove yourself from the situation or event which led to the urge. If you're in a room where others are smoking, and an urge hits, get up and take a short walk. You can walk around the building, or outside, until you feel ready to re-enter the situation--without smoking. Avoid: Avoiding situations where you’ll be tempted to smoke will be particularly important in the first days and weeks after you quit. For example, if you regularly go to places where there’s a lot of smoking, like coffee shops or clubs, it’s best to avoid them for a little while to allow you get used to not smoking. Distract: Another way to control urges is to get busy, get back to what you were doing before the urge hit. Also, there may be other things which you enjoy doing which are incompatible with smoking. Some suggestions we have are working in the yard, reading a magazine, walking, taking a shower or working a crossword puzzle. Substitute: When you feel that you want a cigarette, substitute something else for a cigarette. We suggest sugarless candy or sugarless gum, especially if you are watching your weight. Also, you could eat a piece of fruit, or drink a soft drink. You can also use something to chew on like a straw or a toothpick. The trick is to come up with something you like which can be easily substituted for a cigarette. Go over individual triggers and discuss appropriate DEADS strategies

Provide medication counseling Promote consistent use as prescribed Discuss proper use, with demonstration Discuss concept of “slip” versus relapse Slip Smoking 1 or a few cigarettes Relapse Going back to regular, daily smoking Let a slip slide. Offer to assist throughout quit attempt Follow-up contact #1: first week after quitting Follow-up contact #2: in the first month Additional follow-up contacts as needed and preferably 6 months or more (Remember Tobacco Use Disorder is a CHRONIC Disease) Congratulate the patient! It is imperative that clinicians counsel patients on their pharmacotherapy regimens (proper use, with demonstration as needed) and encourage patients to adhere to the prescribed regimen. Patients should be advised to take cessation medications as prescribed, not as needed. If a patient waits until he or she is in dire need of nicotine, it is too late. Nicotine replacement therapy products do not have the same rapid onset of action as tobacco formulations. Prior to embarking on a quit attempt, the patient should be strongly advised not to smoke an occasional cigarette, or to have “just one drag” off of a friend’s cigarette. These are precursors for a full relapse. But, the patient should know the difference between a slip and a full relapse. A slip is a situation in which a person smokes one or just a few cigarettes. Although this can lead to a full relapse, it is not a complete failure, and it should be considered part of the learning process. If this occurs, encourage the patient to think through the scenario and determine the trigger(s) for smoking. Suggest coping strategies that will enable the patient to avoid smoking in similar situations. The last of the 5 A’s is to arrange follow-up. At this point, the clinician should summarize treatment plans and offer to assist throughout the quit attempt. The most effective timing for follow-up contacts is not well understood (Fiore et al., 2008), and likely will vary by patient. In general, contact should occur the first week after quitting and a few weeks later (within the first month), with additional follow-up contacts as needed until the patient is stable in his or her new role as a nonuser of tobacco. At follow-up contact, it is important to reassess the patient’s commitment to quitting and his or her confidence in quitting. The patient’s response will, in part, be a reflection of his or her confidence in the treatment plan. As needed, offer resources and referrals (e.g., to other health care providers, tobacco quitlines). Finally, congratulate the patient for making the important decision to quit. Fiore MC, Jaén CR, Baker TB, et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service.

2008: Treatment Recommendations – Counseling: For Smokers Not Willing to Make a Quit Attempt at This Time Recommendation: Motivational intervention techniques appear to be effective in increasing a patient’s likelihood of making a future quit attempt. Therefore, clinicians should use motivational techniques to encourage smokers who are not currently willing to quit to consider making a quit attempt in the future. Strength of Evidence = B Some evidence suggests that extensive training is needed before competence is achieved in the MI technique (CPG 2008: p.105) In 2000 guideline – this was strength of evidence C. Now it is B.

Motivational Interventions
I see you are smoking 2 packs a day. As your provider, I’m concerned about the impact on your health. Is it okay if we talk about that for a few minutes? Have you thought about quitting smoking? When you think of the pros and cons of smoking, how do they stack up for you these days? If you look at this list of things you could work on to improve your heart health/HTN…, which one(s) seem like things you might be ready to talk about? Asking the patient rate importance and confidence about quitting can help identify barriers to change and also elicit “change talk” and commitment. Note that the discussion following the number rating is the most important part of using rulers- number matters only in what it means to the person.

Motivational Interviewing: Importance and Confidence Rulers
On a scale of 0 to 10, with 0 meaning not important and 10 meaning very important, how important do you think it is for you to quit smoking? On a scale of 0 to 10, with 0 meaning not at all confident and 10 meaning completely confident, how confident do you feel about quitting? Why are you at a __instead of a (lower number here) __? and/or What would need to happen to make your ____increase to (slightly higher number)___? Asking the patient rate importance and confidence about quitting can help identify barriers to change and also elicit “change talk” and commitment.

Combining Medications & Counseling CPG Table 6
Combining Medications & Counseling CPG Table 6.24: Effectiveness of and estimated abstinence rates for combination of counseling and medication vs. counseling alone (n=9 studies) Intervention Number of Arms Estimated Odds Ratio (95% C.I.) Estimated Abstinence Rate (95% C.I.) Counseling alone 11 1.0 14.6 Medication + counseling 13 1.7 (1.3, 2.1) 22.1 (18.1, 26.8) Providing medications in addition to counseling significantly increases treatment outcomes.

Combining Medications & Counseling CPG Table 6
Combining Medications & Counseling CPG Table 6.22: Effectiveness of and estimated abstinence rates for combination of counseling & medication vs. medication alone (n=18 studies) Intervention Number of Arms Estimated Odds Ratio (95% C.I.) Estimated Abstinence Rate (95% C.I.) Medication alone 8 1.0 21.6 Medication + counseling 39 1.3 (1.1, 1.6) 27.0 (22.7, 31.4) Recommendation: The combination of counseling and medication is more efficacious than either medication or counseling alone. Therefore, when feasible and not contraindicated, both counseling and medication should be provided to patients trying to quit smoking. Strength of Evidence=A

Medications for Smoking Cessation
Monotherapy Combination Therapy Nicotine replacement therapy (NRT) Nicotine patch Nicotine gum Nicotine lozenge Nicotine inhaler Nicotine nasal spray Bupropion Varenicline (2nd line agent) Nortriptyline (not FDA-approved for tobacco cessation) Clonidine (not FDA-approved for tobacco cessation) Nicotine patch + other NRT Bupropion + NRT CPG 2008 Recommendation: Certain combinations of first-line medications have been shown to be effective smoking cessation treatments. Therefore, clinicians should consider using these combinations of medications with their patients who are willing to quit. VA first line options on the National Formulary

How to Assess Nicotine Dependence
Time to first cigarette upon waking better correlated with dependence Brief Fagerström Test for Nicotine Dependence How soon after waking do you smoke your first cigarette? a. Less than five minutes (3 points) b. 5 to 30 minutes (2 points) c. 31 to 60 minutes (1 point) How many cigarettes do you smoke each day? a. More than 30 cigarettes (3 points) b. 21 to 30 cigarettes (2 points) c. 11 to 20 cigarettes (1 point) Scoring: 5-6=heavy dependence; 3-4=moderate; 0-2=light. The first cigarette of the day has the greatest impact on reinforcing the addictive properties of nicotine. Assessing the time to smoking the first cigarette and the amount of cigarettes smoked in a day have the best correlation with dependence on nicotine. The Fagerstrom test is a 30 question test, but can be shortened to this 2 question test to allow for a faster assessment when preforming a brief intervention (less than 5 minutes).

Nicotine Replacement Therapy
Reduces withdrawal symptoms and cravings by providing nicotine in place of smoking Includes: Nicotine patch Nicotine gum Nicotine lozenge Nicotine inhaler and nicotine nasal spray (*not on VA formulary) Best if used in combination During counseling, can check to see if patients are using NRT correctly Before reviewing the individual NRT formulations, it is important to review some general precautions to consider when recommending its use as an aid for cessation. Nicotine activates the sympathetic nervous system leading to an increase in heart rate, blood pressure and myocardial contractility. Nicotine may also cause coronary artery vasoconstriction (Benowitz, 1997). These known hemodynamic effects of nicotine have led to concerns about the safety of using NRT in patients with established cardiovascular disease, particularly those with serious arrhythmias, unstable angina or recent myocardial infarction (less than 2 weeks). Soon after the nicotine patch was approved, there were anecdotal case reports in the lay press linking NRT use (patch and gum) with adverse cardiovascular events (i.e., arrhythmias, myocardial infarction, stroke). Since that time, several randomized, controlled trials have evaluated the safety of NRT in patients with cardiovascular disease including angiographically-documented coronary artery stenosis, myocardial infarction, stable angina and previous coronary artery bypass surgery or angioplasty (Joseph et al., 1996; Tzivoni et al., 1998; Working Group for the Study of Transdermal Nicotine in Patients with Coronary Artery Disease, 1994). The results of these trials suggest there is no significant increase in the incidence of cardiovascular events or mortality among patients receiving NRT when compared to placebo. However, because these trials specifically excluded patients with unstable angina, serious arrhythmias and recent myocardial infarction, the Clinical Practice Guideline recommends that NRT be used with caution among patients in the immediate (within two weeks) postmyocardial infarction period, those with serious arrhythmias, and those with serious or worsening angina due to a lack of safety data in these high-risk populations (Fiore et al., 2000). The use of NRT in patients with cardiovascular disease has been the subject of numerous reviews and it is widely believed by experts in the field that the risks of NRT in this patient population are small relative to the risks of continued tobacco use (Benowitz & Gourlay, 1997; McRobbie & Hajek, 2001; Silagy et al., 2002; Benowitz, 2003; Joseph & Fu, 2003). In sum, NRT is safe in patients with stable cardiovascular disease. NRT should be used with caution in patients with unstable cardiovascular conditions: 1) recent MI- within 2 weeks, 2) life-threatening arrhythmias, and 3) unstable angina. Benowitz NL. The role of nicotine in smoking-related cardiovascular disease. Prev Med 1997;26:412–417. Benowitz NL. Cigarette smoking and cardiovascular disease: pathophysiology and implications for treatment. Prog Cardiovasc Dis 2003;46(1): Benowitz NL, Gourlay SG. Cardiovascular toxicity of nicotine: Implications for nicotine replacement therapy. J Am Coll Cardiol 1997;29:1422–1431. 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, 2000. Joseph AM, Norman SM, Ferry LH, et al. The safety of transdermal nicotine as an aid to smoking cessation in patients with cardiac disease. N Engl J Med 1996;335:1792–1798. Joseph AM, Fu SS. Safety issues in pharmacotherapy for smoking in patients with cardiovascular disease. Prog Cardiovasc Dis 2003;45(6): McRobbie H, Hajek P. Nicotine replacement therapy in patients with cardiovascular disease: guidelines for health professionals. Addiction 2001;96(11): Silagy C, Lancaster T, Stead L, Mant D, Fowler G. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2002;4:CD Tzivoni D, Keren A, Meyler S, et al. Cardiovascular safety of transdermal nicotine patches in patients with coronary artery disease who try to quit smoking. Cardiovasc Drugs Ther 1998;12(3): Working Group for the Study of Transdermal Nicotine in Patients with Coronary Artery Disease. Nicotine replacement therapy for patients with coronary artery disease. Arch Intern Med 1994;154(9):

Plasma Nicotine Concentrations for Nicotine-Containing Products
Cigarette Moist snuff This graph depicts the plasma venous nicotine concentrations achieved with the various nicotine delivery systems. Peak plasma concentrations are higher and are achieved more rapidly when nicotine is delivered via cigarette smoke compared to the available NRT formulations. Among the NRT formulations, absorption is fastest with the nasal spray, followed by the gum, lozenge and inhaler; absorption is slowest with the transdermal formulations. The concentration time curves in this slide depict levels achieved after administration of a single dose of nicotine following a period overnight abstinence. The administration of nicotine varies with the cigarette smoked over 5 minutes, the moist snuff (2 grams) placed between the check and gum for 30 minutes, inhaler used over 20 minutes (80 puffs), gum chewed over 30 minutes, the lozenge held in the mouth for approximately 30 minutes and the patch applied to the skin for 1 hour. The data presented in the graph are from multiple studies and are meant to illustrate the differences between nicotine absorption from tobacco and NRT (Fant et al., 1999; Schneider et al., 2001; Choi et al., 2003). Because NRT formulations deliver nicotine more slowly and at lower levels (e.g., 30–75% of those achieved by smoking), these agents are far less likely to be associated with dependence when compared to tobacco-based products. Choi JH, Dresler CM, Norton MR, Strahs KR. Pharmacokinetics of a nicotine polacrilex lozenge. Nicotine Tob Res. 2003;5(5): Fant RV, Henningfield JE, Nelson RA, Pickworth WB. Pharmacokinetics and pharmacodynamics of moist snuff in humans. Tob Control 1999;8(4): Schneider NG, Olmstead RE, Franzon MA, Lunell E. The nicotine inhaler. Clinical pharmacokinetics and comparison with other nicotine treatments. Clin Pharmacokinet 2001;40(9):661–684. Time (minutes)

Nicotine Patch Provides a continuous source of nicotine through the skin Replaced every 16 – 24 hours Site on skin is rotated to prevent skin irritation More effective if used in combination with nicotine gum or lozenge ad lib for strong cravings If trouble sleeping – recommend patients remove before sleeping For more information on nicotine patch dosing see: Dosing instructions and adverse drug reactions are presented on this slide for the nicotine patch. Dosing is adjusted for smokers who smoke less than 10 cigarettes per day. Note that duration can be extended.

Nicotine Gum “Bite and Park” method
Patient bites down on gum a few times until tastes nicotine (peppery) or feels tingling sensation Gum is parked between the cheek and gum until taste/sensation goes away Bite and repeat until gum has lost its taste (~30 min) Remind patients not to use like chewing gum Can be used ad lib to control strong tobacco cravings Do not eat or drink for 15 min before or after using gum. Acidic beverages (soda, coffee) can reduce nicotine absorption If patient has nausea – check to see if they are using the gum correctly For more information on nicotine gum dosing see: ***Alternative dosing and titrating based on # of nicotine gum may more better. For example, Pt should start with at least 9 pieces of nicotine gum/day and decrease by 1 every week*** Week 1: 10 pieces Week 2: 9 pieces And so forth Advantages of nicotine gum include the following: Gum use may satisfy oral cravings. Gum use may delay weight gain (Fiore et al., 2000). Patients can titrate therapy to manage withdrawal symptoms. Disadvantages of the gum include the following: Gum chewing may not be socially acceptable. Gum may stick to dental work and dentures. Patients must use proper chewing technique to minimize adverse effects. The gum appears to be particularly helpful with patients who have weight gain concerns or who report boredom as a trigger for smoking. It may also be advantageous for persons who need to more tightly titrate nicotine levels to avoid distraction or irritability withdrawal symptoms in order to avoid injury, such as transportation workers or persons who work with heavy machinery. Fiore MC, Jaén CR, Baker TB, et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service.

Nicotine Lozenge Place lozenge in mouth and park between the cheek and gum Occasionally move from one side of the mouth to the other Do not eat the lozenge, avoid swallowing Do not use like a hard candy If patient has nausea – check to see if they are using the lozenge correctly Can be used ad lib to control strong tobacco cravings Nicotine absorbed through the lining of the mouth Do not eat or drink for 15 min before or after using the lozenge. Acidic beverages (soda, coffee) can reduce nicotine absorption For more information on nicotine lozenge dosing see: ***Alternative dosing and titrating based on # of nicotine lozenge may more better. For example, Pt should start with at least 9 pieces of nicotine lozenge/day and decrease by 1 every week*** Week 1: 10 pieces Week 2: 9 pieces And so forth Advantages of nicotine gum include the following: Gum use may satisfy oral cravings. Gum use may delay weight gain (Fiore et al., 2000). Patients can titrate therapy to manage withdrawal symptoms. Disadvantages of the gum include the following: Gum chewing may not be socially acceptable. Gum may stick to dental work and dentures. Patients must use proper chewing technique to minimize adverse effects. The gum appears to be particularly helpful with patients who have weight gain concerns or who report boredom as a trigger for smoking. It may also be advantageous for persons who need to more tightly titrate nicotine levels to avoid distraction or irritability withdrawal symptoms in order to avoid injury, such as transportation workers or persons who work with heavy machinery. Fiore MC, Jaén CR, Baker TB, et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service.

Bupropion Atypical antidepressant that reduces cravings and symptoms of withdrawal Can be used in combination with NRT Use with extreme caution in patients that: Are currently taking medication for depression or another mental health disorder Have a history of seizures Have an eating disorder Bupropion should be used with extreme caution patients with a history of seizure, cranial trauma, or in patients treated with medications that may lower the seizure threshold (e.g., antipsychotics, antidepressants, theophylline, systemic steroids, etc.). Hepatic Impairment: Bupropion should be used with extreme caution in patients with severe hepatic cirrhosis. In these patients a reduced frequency of dosing is required, as peak bupropion levels are substantially increased and accumulation is likely to occur in such patients to a greater extent than usual. The dose should not exceed 150 mg every other day in these patients. GlaxoSmithKline Inc. Zyban Package Insert. Research Triangle Park, NC: 2003, March. Black Box Warning: Risk of serious neuropsychiatric events including behavior change, hostility, agitation, depression, and suicidality as well as worsening of pre-existing psychiatric illness in patients taking bupropion and after discontinuation.

Varenicline Partial nicotinic receptor agonist
Reduces tobacco cravings and symptoms of withdrawal and also makes tobacco use less enjoyable Should not be used in combination with NRT or bupropion Varenicline is a 2nd line agent in VA. It can be used only in patients that: Have already tried to quit smoking with NRT or bupropion Have been screened for hopelessness and suicidal ideation and judged to be stable by their primary care or mental health provider Receive close follow-up from their health care provider Commonly causes nausea and sleep disturbances Rarely causes patients to have violent thoughts, intent, or actions towards themselves or others Summarize the neuropsychiatric symptoms Black Box Warning: Risk of serious neuropsychiatric events including behavior change, hostility, agitation, depression, and suicidality as well as worsening of pre-existing psychiatric illness in patients taking varenicline and after discontinuation.

Estimated Odds Ratio (95% C.I.) Estimated Abstinence Rate (%)
Effectiveness of Monotherapies CPG Table 6.26: Effectiveness and abstinence rates for monotherapies vs placebo at 6 months postquit (n=83 studies) Medication Number of Arms Estimated Odds Ratio (95% C.I.) Estimated Abstinence Rate (%) Placebo 80 1.0 13.8 Varenicline 2mg/d 5 3.1 (2.5,3.8)* 33.2 Nic. Nasal Spray 4 2.3 (1.7,3.0)* 26.7 High dose nic patch >25mgs 26.5 Long term nic gum >14 weeks 6 2.2 (1.5,3.2)* 26.1 Varenicline 1mg/d 3 2.1 (1.5,3.0)* 25.4 Nicotine inhaler 2.1 (1.5,2.9)* 24.8 Bupropion SR 26 2.0 (1.8,2.2)* 24.2 Nicotine patch 32 1.9 (1.7,2.2)* 23.4 Long term nic patch >14 weeks 10 1.9 (1.7,2.3)* 23.7 Nicotine gum 15 1.5 (1.2,1.7)* 19.0 This chart summarizes meta-analyses findings of monotherapies vs placebo at 6 months post quit - Pulls in new medications, as well as data from dosages and durations Busy chart, I included only the odd ration and abst rate estimates and omitted the CI to make it easier to read. I refer you to the actual tables if you wish to see the CI Compared to placebo all of the medications increased the likelihood of long term abstinence from tobacco at 6 months. Most approximately doubled quit rates compared to placebo The outlier is varenicline 2mg qd, which tripled quit rates compared to placebo, and was associated with greater abstinence rates at 6 months. Caveat: All the varenicline trials were sponsored by the pharmaceutical industry. Varenicline 1 mg also doubled quit rate – this may be a good option for patients who can not take/tolerate varenicline 2 mg Nicotine patch high dose (> 25 mgs, experimental), standard dose patch, long term patch > 14 weeks entered into meta analysis. See data on nicotine patch standard – 32 arms studied with standard dosages typically 14 – 25 mgs. Doubled quit rates compared to placebo. Now look at high dose nic patch – experiemental trials with patch dosages exceeding 25 mgs, ranging from mgs. This also roughly doubled quit rates. Similarly long term nic patch where patch treatment extended beyond 14 wks – also roughly doubled quit rates and had same odds ratio as standard nicotine patch. All roughly doubled 6 month quit rates compared to placebo. Not a big difference between them – so date indicates that all of the nicotine patch treatments doubled quit rates, and that there was no appreciable benefit produced above and beyond standard dose and standard duration patch Gum – Standard duration is 12 weeks. Data shows that standard duration gum was more effective than placebo, increasing likelihood of long term abstinence by 50%. There were 6 arms that studied longer term gum use – 5 of 6 of these arms carried out nicotine gum for 52 weeks. Data suggests that the long term use gum was particularly effective, doubling quit rates compared to placebo

Estimated Odds Ratio (95% C.I.) Estimated Abstinence Rate (%)
Effectiveness of Combination Therapies CPG Table 6.26: Effectiveness and abstinence rates for smoking medication combinations vs. placebo at 6 months postquit (n=83 studies) Medications Number of Arms Estimated Odds Ratio (95% C.I.) Estimated Abstinence Rate (%) Placebo 80 1.0 13.8 Patch (>14wks) ad lib NRT 3 3.6 (2.5,5.2)* 36.5 Patch + Bupropion 2.5 (1.9,3.4)* 28.9 Patch+Nortriptyline 2 2.3 (1.3,4.2)* 27.3 Patch + Inhaler 2.2 (1.3,3.6)* 25.8 2nd gen. antidep + patch 2.0 (1.2,3.4)* 24.3 Chart compares various combinations of meds + patch compared to placebo at 6 months post quit. All doubled quit rates or more compared to placebo Notable outlier is patch – long term > 14 weeks + ad lib NRT – gum or spray. 3 arms showed that this combination more than tripled quit rates compared to placebo. In the three trials All had long term patch exceeding 14 weeks – durations of weeks. 2 studies used gum, one used spray. The 2 gum arms both used 2 mg gum for 26 weeks in one arm and 52 weeks in another. Third arm was nasal spray for 52 weeks. Suggests long term patch and ad lib but fairly long term gum is particularly helpful Note that where high dose patch was not associated with greater outcome than standard dose, the combination of patch + another form of NRT was more useful, particularly patch + ad lib nrt. The other combiations also increased quit rates compared to placebo – around doubling relative outcome rates. 2nd gen antidepressants studied were paxil and venlafaxine. CPG recommends Patch + ad lib nrt, / bup/ inhaler – the others are not recommended as they are not first line medications. May be particularly useful for smokers who are having difficulty quitting with a single front line treatment Clinician should consider effectiveness, but also cost of double meds, side effects, tolerability, and patient motivation and compliance to take more than one medication. Certain combinations of first-line medications have been shown to be effective Strength of evidence: A Effective combinations are long term nic patch + ad lib NRT, nic patch + inhaler, nic patch + bupropion Long term patch + ad lib NRT associated with highest quit rates vs. placebo Patch + nortrip/2nd gen. antidepressants not FDA approved, not recommended Clinicians should consider factors of cost, tolerability, compliance

Clinical Case Discussion #1
CT is a 55y/o male who smokes between packs per day, lately towards the high end due to inactivity in the winter. During the summer he keeps busy outside with gardening and fishing. He and his wife are planning to quit smoking together on New Year’s Day, but are not sure about the best way. Recently his best friend was diagnosed with lung cancer. They both started smoking together when they were 15. CT wants to avoid going through anything like that. Discussion: What questions would you ask CT? How would you recommend CT try to quit smoking? What strategies would you use? Case descriptions – give scenario, example of patient. Have audience either role-play with each other, then discuss as a larger group, or just ask for audience input. Use 5 A’s Discuss key issues, barriers

TG is a 60y/o man who smokes 1 ppd. He has been smoking for most of his life. He’s come in today for counseling related to his COPD. “I've thought about quitting smoking, but I don’t think it would do much good, my lungs are so bad and I have already had a heart attack. You medical people seem to think you know what is best for people, but what do you know about me. I have a lot of stress and this is how I deal with it.” -TG Discussion: What questions would you ask TG? How would you talk to TG about quitting? Case descriptions – give scenario, example of patient. Have audience either role-play with each other, then discuss as a larger group, or just ask for audience input. Motivational interviewing 5 A’s

GS is a 45 year old man who is being discharged from the hospital after having 4-vessel CABG. He smoked 2 packs per day prior to hospitalization. He has not smoked since the surgery and has worn a nicotine patch during hospitalization. As he prepares to go home, he admits he is concerned about having cravings at home because his wife smokes. He wants to quit and is afraid of having more heart problems. He’s not sure if his wife will smoke outside, since she's done so much for him lately. He usually spends evenings together with his wife watching TV together and smoking to relax. Discussion: GS has already quit – how would you help him? DEADS strategy for coping with cravings Discuss barriers to quitting – wife smoking 5 A’s

National VA Tobacco Cessation Resources
VHA Tobacco and Health intranet site also has additional information on policy and clinical resources that are available: vaww.publichealth.va.gov/smoking/index.asp Providers can contact the VHA Clinical Public Health Program for any questions at: Monthly VHA Tobacco Cessation Clinical Update Audio Conference Series that is supported by EES that provides CEUs. For information on this, please contact: VA Tobacco Cessation SharePoint site: vaww.portal.va.gov/sites/tobacco/default.aspx VHA Pharmacy Benefits Management: National VA tobacco cessation resources are listed on this slide.

Useful Links for VA Information
VA Varenicline Prescribing Criteria: Recommendations for Use of Combination Therapy in Tobacco Use Cessation: vaww.publichealth.va.gov/docs/smoking/combo_NRT_recomm.pdf VA Tobacco Use Cessation Treatment Guidance; Medication options:

Additional Tobacco Cessation Resource
Collaboration with VA Clinical Public Health and DoD TRICARE Web-based resource: Self-management tools and resources Live chat services with a coach Community support forum and blog VHA posters and Veteran wallet cards distributed to facilities and stocked in VA Forms Depot Available online at: vaww.publichealth.va.gov/smoking/clinical.asp

SMOKING CESSATION AND MENTAL HEALTH POPULATIONS

Copyright © 1999-2011 The Regents of the University of California.
All rights reserved. Portions of this program were adapted, with permission, from the Rx for Change: Clinician-Assisted Tobacco Cessation program VA Tobacco Use Cessation Program Curriculum Committee: Jeannie Beckham, Ph.D. Timothy Carmody, Ph.D., Timothy Chen, Ph.D., Dana Christofferson, Ph.D., Judith Cooney, Ph.D., Margaret Dundon, Ph.D., Steven Fu, MD, MSCE, Kim Hamlett-Berry, Ph.D., Miles McFall, Ph.D. 58

OVERVIEW—Second Hour Tobacco Use in Mental Health and Substance Use Disorder Populations Treatment Research for Co-Occurring Disorders VA Tobacco Cessation Resources National Local

Tobacco Use in Mental Health Populations: The Problem
Nicotine dependence – most prevalent substance use disorder among psychiatric patients Smoking rates are 2 to 4 x’s that of the general population (Hughes, 1993; Poirier, 2002) Persons with mental illness comprise 44% to 46% of the US tobacco market (Lasser et al., 2000; Grant et al., 2004) 175 billion cigarettes and $39 billion in annual sales (USDA, 2004) 40.6% of smokers had a mental illness in the past month (Lasser et al., 2000) Among medical specialists, psychiatrists are the least likely to address tobacco use with their patients (Association of American Medical Colleges, 2007) Often heavy smokers, the mentally ill comprise 44% to 46% of the US tobacco market. In terms of dollars spent, this equates to 175 billion cigarettes and $39 billion in annual tobacco sales. Mental illness is associated with lower rates of quitting and higher rates of relapse, making it likely that without innovative treatments, individuals with mental illness will constitute a growing proportion of the smoking population. Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smoking and mental illness: A population-based prevalence study. JAMA. Nov ;284(20): Grant BF, Hasin DS, Chou SP, Stinson FS, Dawson DA. Nicotine dependence and psychiatric disorders in the United States: results from the national epidemiologic survey on alcohol and related conditions. Arch Gen Psychiatry. Nov 2004;61(11): Federal Trade Commission Cigarette Report for Washington, D.C.: Federal Trade Commission.; 2005. Hughes JR. Possible effects of smoke-free inpatient units on psychiatric diagnosis and treatment. J Clin Psychiatry. Mar 1993;54(3): Poirier MF, Canceil O, Baylé F, Millet B, Bourdel MC, Moatti C, Olié JP, Attar-Lévy D Prevalence of smoking in psychiatric patients. Prog Neuropsychopharmacol Biol Psychiatry Apr;26(3):

Tobacco Kills People with Mental Illness
Tobacco users with mental illness die 25 years earlier than non-users (Colton & Manderscheid, 2006) Tobacco users with mental illness have a greater risk of dying from CVD, respiratory illnesses, and cancer, than people without mental illness (e.g., Dalton et al., 2002; Himelhoch et al., 2004; Lichtermann et al., 2001) Tobacco use predicts future suicidal behavior Independent of depressive symptoms, prior suicidal acts, and other substance use (Breslau et al., 2005; Oquendo et al., 2004) On average, in the general population, female and male smokers die 13.2 & 14.5 years earlier than nonsmokers (MMWR 2002;51:300) A recent report from the US Center for Mental Health Services estimates that on average individuals with serious mental illness are dying 25 years prematurely, with major causes of death being chronic, tobacco-related diseases (Colton & Manderscheid, 2006). The mentally ill are at elevated risk for respiratory and cardiovascular diseases and cancer, compared to age-matched controls (Brown et al., 2000; Bruce et al., 1994; Dalton et al., 2002; Himelhoch et al., 2004; Lichtermann et al., 2001; Sokal et al., 2004). Current tobacco use is predictive of future suicidal behavior, independent of depressive symptoms, prior suicidal acts, and other substance use (Breslau et al., 2005; Oquendo et al., 2004, Potkin et al., 2003). Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis. Apr 2006;3(2):A42. Carney CP, Jones LE. Medical comorbidity in women and men with bipolar disorders: a population-based controlled study. Psychosom Med. Sep-Oct 2006;68(5): Dalton SO, Laursen TM, Mellemkjaer L, Johansen C, Mortensen PB. Risk for cancer in parents of patients with schizophrenia. Am J Psychiatry. 2004;161:903-8. Lichtermann D, Ekelund J, Pukkala E, Tanskanen A, Lonnqvist J. Incidence of cancer among persons with schizophrenia and their relatives. Arch Gen Psychiatry. Jun 2001;58(6): Ruschena D, Mullen PE, Burgess P, et al. Sudden death in psychiatric patients. Br J Psychiatry. Apr 1998;172: Bruce ML, Leaf PJ, Rozal GP, Florio L, Hoff RA. Psychiatric status and 9-year mortality data in the New Haven Epidemiologic Catchment Area Study. Am J Psychiatry. May 1994;151(5): Goff DC, Sullivan LM, McEvoy JP, Meyer JM, Nasrallah HA, Daumit GL, et al. A comparison of ten-year cardiac risk estimates in schizophrenia patients from the CATIE study and matched controls. Schizophr Res. 2005;80:45-53. Hurt RD, Offord KP, Croghan IT, et al. Mortality following inpatient addictions treatment. Role of tobacco use in a community-based cohort. JAMA. Apr ;275(14): Himelhoch S, Lehman A, Kreyenbuhl J, Daumit G, Brown C, Dixon L. Prevalence of chronic obstructive pulmonary disease among those with serious mental illness. Am J Psychiatry. 2004;161: Oquendo MA, Galfalvy H, Russo S, et al. Prospective study of clinical predictors of suicidal acts after a major depressive episode in patients with major depressive disorder or bipolar disorder. Am J Psychiatry Aug;161(8): Breslau N, Schultz LR, Johnson EO, Peterson EL, Davis GC. Smoking and the risk of suicidal behavior: a prospective study of a community sample. Arch Gen Psychiatry Mar;62(3):

Smoking Rate by Psychiatric History
41.0% Overall While the prevalence of cigarette smoking among US adults has steadily declined since the first Surgeon General’s report on smoking and health in 1964, rates remain elevated among psychiatric populations. The smoking prevalence among individuals with a current psychiatric illness is nearly double that of individuals without mental illness (41% vs. 23%) and even higher among the seriously mentally ill and those with comorbid substance abuse problems. Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smoking and mental illness: A population-based prevalence study. JAMA. Nov ;284(20): Data from the National Comorbidity Survey, Nationally-representative sample N=4411, aged 15 to 54 years old Structured clinical interviews used to establish DSM-IV criteria for current or past mental illness. Current defined as past month. Disorders assessed were anxiety disorders, mood disorders, nonaffective psychosis, ASPD, conduct disorder, and alcohol and drug abuse/dependence. ** Note: The rates of tobacco use by psychiatric diagnostic category vary in the literature by the type of populations sampled. This study was a national population sample. Active National Comorbidity Survey Source: Lasser et al., 2000 JAMA

Smoking Rate by Psychiatric History in VA
Smoking rates among VA patients with mental illness Current overall smoking rate in VA % Odds ratio of being a current smoker compared to not having a mental disorder: Schizophrenia 1.78 Bipolar disorder 1.46 Depression 1.18 PTSD 0.95 Substance use 2.74 Analysis of 2007 VHA Outpatient Survey of Healthcare Experiences of Patients Duffy SA, Kilbourne AM, Austin KL, Dalack GW, Woltmann EM, Waxmonsky J, Noonan D Risk of smoking and receipt of cessation services among Veterans with mental disorders. Psychiatric Services. 63 (4): Duffy et al., 2012

Tobacco Use Complicates Psychiatric Treatment
Tobacco smoke can induce cytochrome P450 enzymes (CYP1A2) Nicotine itself does not have this effect Inducing cytochrome P450 can affect other drugs by altering: Absorption Distribution This may alter the effectiveness of certain medications Metabolism of some antidepressants and antipsychotic medications can be increased by tobacco smoke, lowering blood levels and possibly reducing the therapeutic benefit Metabolism Elimination

Pharmacokinetic Drug Interactions with Smoking
Some drugs may have a decreased effect due to tobacco smoke induction of CYP1A2: Caffeine Clozapine (Clozaril™) Fluvoxamine (Luvox™) Haloperidol (Haldol™) Olanzapine (Zyprexa™) Phenothiazines (Thorazine, Trilafon, Prolixin, etc.) Propanolol Tertiary TCAs / cyclobenzaprine (Flexaril™) Thiothixene (Navane™) Other medications: estradiol, mexiletene, naproxen, phenacetin, riluzole, ropinirole, tacrine, theophyline, verapamil, r-warfarin (less active), zolmitriptan Tobacco smoke may interact with medications through pharmacokinetic or pharmacodynamic mechanisms. Pharmacokinetic interactions affect the absorption, distribution, metabolism, or elimination of other drugs, potentially causing an altered response. Polycyclic aromatic hydrocarbons (PAHs) in tobacco are responsible for induction of cytochrome P450 enzymes (CYP1A1, CYP1A2, and possibly CYP2E1 and CYP3A). The majority of drug interactions with tobacco smoke are pharmacokinetic, resulting from the induction of drug-metabolizing enzymes (especially CPY1A2) by compounds in tobacco smoke. All of these drugs are metabolized via CYP1A2. Induction of CYP1A2 by PAHs in tobacco smoke will increase metabolism, resulting in potentially clinically significant decreased pharmacologic effects of the following drugs. Following smoking cessation, a patient titrated on these medications may experience enhanced pharmacologic effects or toxicity: Bendamustine (Treanda): Bendamustine is metabolized by CYP1A2. Manufacturer recommends caution in using this drug in smokers as lower bendamustine concentrations may occur, with increased concentrations of its 2 active metabolites (Cephalon, Inc, 2008). Caffeine: Clearance is increased by 56%. It is reasonable to advise patients to decrease their intake of caffeinated beverages when quitting smoking, because nicotine withdrawal effects might be enhanced by increased caffeine levels. Clozapine (Clozaril): Studies have shown mixed results on the clinically significant changes in clozapine levels in smokers. However, upon cessation, a mean increase of 57.4% in clozapine levels has been demonstrated. Doses should be closely monitored upon smoking cessation to avoid high levels and increased toxicity (Meyer 2001). Erlotinib (Tarceva): Clearance of this injectable antineoplastic agent used for pancreatic and non-small cell lung cancer is increased 24% with ~2-fold lower trough concentrations compared to nonsmokers (OSI Pharmaceuticals, 2007). Fluvoxamine (Luvox): Clearance of this antidepressant is increased by 24%; plasma concentrations are decreased by 32%. Yoshimura et al. (2002) determined that plasma fluvoxamine concentrations were significantly lower in smokers (by 39%) compared with nonsmokers. Dosage modifications are not routinely recommended, but smokers might require higher dosages. Inhaled insulin: The absorption of inhaled insulin (Exubera) was shown to be increased 2- to 5-fold in smokers when compared to non-smokers (Pfizer, 2006). While Exubera was removed from the market in 2007, future inhaled insulin products may be released so assessment of smoking status will be important before using an inhaled insulin. Olanzapine (Zyprexa): Clearance of this atypical antipsychotic is increased by 40–98%. Gex-Fabry et al. (2003) showed that smokers had significantly lower concentrations (by 12%) compared with nonsmokers. Dosage modifications are not routinely recommended, but smokers might require higher dosages to achieve clinical response (Carrillo et al. 2003). Ropinirole (Requip): Plasma concentrations may be reduced in smokers and dose increase may be required. In a study of patients with restless leg syndrome, Cmax and AUC were reduced by 38% and 30% respectively in smokers compared to nonsmokers (GlaxoSmithKline, 2006). Tacrine (Cognex): Clearance is substantially increased in smokers. The manufacturer states that mean plasma tacrine concentrations in smokers are threefold lower than those achieved in nonsmokers. The half-life of tacrine is decreased by 50%. Smokers might require higher dosages. Theophylline: Clearance is increased by 58–100%; half-life is decreased by 63%. Closely monitor theophylline levels if smoking is initiated, discontinued, or changed. Maintenance doses are considerably higher in smokers. Within 7 days of smoking cessation, theophylline clearance might decrease by 35%. Note: A similar interaction occurs with aminophylline. PAHs also induce the enzymes involved in glucuronic acid conjugation. Propranolol, mexiletine and codeine have been reported to have increased rates of glucuronidation in smokers. Irinotecan (Camptosar): Clearance of this antineoplastic agent for colorectal cancer is increased by 18%; lower levels of irinotecan and its active metabolite, SN-38 (~40% lower) occur mainly due to induction of the UGT1A1, which conjugates SN-38 and possibly CYP3A. Reduced systemic exposure of SN-38 results in lower toxicity (e.g., hematologic) and likely reduced efficacy; dose increases may be required (van der Bol 2007; Benowitz 2007). Q&A with Dr. Neal Benowitz What level of tobacco use is needed to have the drug interactions? Is it a dose response relationship? > Not much data about this. Without the data, the assumption is that any smoker is susceptible to the same degree of interaction. Does nicotine have any drug interaction effects? > Nicotine should not affect drug metabolism. Nicotine, however, may interact via its stimulant effects and reduce the sedation caused by other drugs 3) How long does it take to see drug interaction effects with smoking tobacco? > Enzyme induction begins within a few days and peaks probably in a week or so. De-induction begins rapidly, but may also take a week or two to see full dissipation of effects. Benowitz NL. (2007). Cigarette smoking and the personalization of irinotecan therapy. J Clin Oncol 25:2646–2647. Carrillo JA, Herraiz AG, Ramos SI, Gervasini G, Vizcaino S, Benitez J. (2003). Role of the smoking-induced cytochrome P450 (CYP)1A2 and polymorphic CYP2D6 in steady-state concentration of olanzapine. J Clin Psychopharmacol 23:119–127. Cephalon, Inc. (2008). Treanda Package Insert. Frazer, PA. Gex-Fabry M, Balant-Gorgia AE, Balant LP. (2003). Therapeutic drug monitoring of olanzapine: The combined effect of age, gender, smoking and comedication. Ther Drug Monit 25:46–53. GlaxoSmithKline. (2006). Requip Package Insert. Research Triangle Park, NC. Meyer JM. (2001). Individual changes in clozapine levels after smoking cessation: results and a predictive model. J of Clin Psychopharmacol 21:569–574. OSI Pharmaceuticals, Inc. and Genentech, Inc. (2007, May). Tarceva Package Insert. Melville, NY. Pfizer, Inc. (2006, May). Exubera Package Insert. New York, NY. van der Bol JM. (2007). Cigarette smoking and irinotecan treatment: pharmacokinetic interaction and effects on neutropenia. J Clin Oncol 25:2719–2726. Yoshimura R, Ueda N, Nakamura J, Eto S, Matsushita M. (2002). Interaction between fluvoxamine and cotinine or caffeine. Neuropsychobiology 45:32–35. Smoking cessation will reverse these effects. 65

Decreasing Rates of Tobacco Use in Mental Health Populations: The Solution
Effective treatments exist that can significantly increase rates of long-term abstinence and are supported by the 2008 United States Public Health Services Update of Clinical Practice Guidelines on the Clinical Treatment of Tobacco Use and Dependence (USPHS CPG). Policies that reduce smoking prevalence: Increasing tobacco taxes Smoke-free workplace, restaurant, and bar laws Changes in cultural norms around smoking and tobacco use A summary of the 2008 Public Health Guidelines were provided in the Pre-symposium materials. Use of tobacco cessation medications can more than double success rates for quitting tobacco.

CPG 2008: Main Findings on Treating Tobacco Use
Every smoker should be screened for tobacco use and willingness to quit at each session All smokers should be offered pharmacotherapy to assist in quitting Brief advice given by MD and non-MD clinicians effective in increasing quit rates Dose response relationship between counseling intensity and effectiveness While more intensive counseling is more efficacious, even brief counseling (2 minutes) can double quit rate The main findings on treating tobacco use are summarized in this slide.

De-normalization of Tobacco Use
Many states have banned smoking in workplaces, bars, and restaurants Some cities and states are also contemplating laws regulating smoking in public housing and apartment buildings, as well as outdoor spaces With fewer places to smoke, smokers have become increasingly marginalized As rates of tobacco use have declined, those who use tobacco are disproportionately less educated and of a lower socioeconomic status Image of a smoker has changed from “handsome, successful” to “asocial, irresponsible, and self-destructive” This de-normalization has helped with tobacco control efforts and to induce smokers to quit, however some worry that this tactic has resulted in the stigmatization of smokers The stigma attached to smoking may further marginalize individuals who are already stigmatized due to their mental illness - is this the solution, or part of the problem for MH populations? Does this increase their stigmatization? Bayer & Stuber, 2006

Readiness to Quit in Patients with Psychiatric Disorders
Smokers with mental illness or addictive disorders are just as ready to quit smoking as the general population of smokers. Recent studies of readiness to quit among individuals with mental illness indicate over 20% are intending to quit in the next 30 days (Preparation stage of change) and another 40% intend to quit in the next 6 months (Contemplation stage). These rates are comparable to those reported in the general population. Further, the studies have reported no relationship between severity of psychiatric symptoms and intention to quit smoking. References: General Psychiatry Outpatients: Acton et al. (2001). Depression and stages of change for smoking in psychiatric outpatients. Addictive Behaviors. 26(5): Depressed Outpatients: Prochaska et al. (2004). Depressed smokers and stage of change: implications for treatment interventions. Drug Alc Dep. 76(2): Psychiatric Inpatients: Prochaska et al. (2006). Return to smoking following a smoke-free psychiatric hospitalization. Am J Addiction. 15(1):15-22. Methadone Clients: Nahvi et al. (2006) Cigarette smoking and interest in quitting in methadone maintenance patients. Addictive Behaviors. 31(11): * No relationship between psychiatric symptom severity and readiness to quit

Integration of Smoking Cessation into MH and SUD Care
2000 PHS CPG – Smokers with MH disorders should be provided with the same level of smoking cessation treatment as the general population (Fiore et al., 2000) 2008 update of CPG – Included an emphasis to practitioners to treat smokers with MH and SUD disorders (Fiore et al., 2008) Why do so few MH treatment programs provide smoking cessation treatment to their patients? Potential barriers include perceptions that quitting smoking will adversely affect patients’ psychiatric functioning or interfere with abstinence from drugs or alcohol, and lack of training of mental health professionals in evidence-based smoking cessation care (Hall and Prochaska, 2009)

Why Mental Health Providers?
“ Those who deliver mental health care often pride themselves on treating the whole patient….yet many fail to treat nicotine dependence. They forget that when their patient dies of a smoking-related disease, their patient has died of a psychiatric illness they failed to treat.” John Hughes is a Professor of Psychiatry and Tobacco Control Research at the University of Vermont. Dr. John Hughes

Why Mental Health Providers?
Frequent contact with the patient and existing therapeutic relationship Appropriate to address smoking as a chronic disorder Have the skills to deliver tobacco cessation counseling Expertise in behavioral and counseling treatment Many trained in substance abuse treatment Able to identify and address any changes in psychiatric symptoms during the quit attempt Improved outcomes compared to referring patients to smoking cessation clinic care (McFall et al., 2010) CPG 2008: …such treatments could be conveniently delivered within the context of chemical dependence or mental health clinics. Tobacco users expect to be encouraged to quit by health professionals. In a study examining whether health habit counseling affects patient satisfaction, Barzilai et al. (2001) determined that of 12 health habits examined (exercise, diet, alcohol history, alcohol counseling, tobacco history, tobacco counseling, passive tobacco exposure, contraception and condom use, substance use history, substance use counseling, STD prevention, and counseling about HIV testing or prevention), only tobacco history and tobacco counseling were significantly associated with full satisfaction with the clinician visit. A clinician who does not address tobacco use during a clinical encounter tacitly implies that quitting is not important. Barzilai DA, Goodwin MA, Zyzanski SJ, Stange KC. (2001). Does health habit counseling affect patient satisfaction? Prev Med 33:595–599. Mental health providers are particularly well positioned to address tobacco use with their clients because: Often the clinician for whom contact is the most frequent and who knows the patient best Able to combine psychopharmacological and behavioral/counseling treatment Trained in substance abuse treatment Able to identify and address any changes in psychiatric symptoms during the quit attempt

Quit Rates in Patients with Psychiatric Disorders
Lifetime diagnosis U.S. Population (%) Current Smoker (%) Lifetime Smoker (%) Smoking Quit Rates (%) No psychiatric diagnosis 50.7 22.5 39.1 42.5 PTSD 6.4 45.3 63.3 28.4 Major depression 16.9 36.6 59.0 38.1 Dysthymia 6.8 37.8 60.0 37.0 Bipolar disorder 1.6 68.8 82.5 16.6 Smoking quit rate defined as proportion of lifetime smokers who were not current smokers. Schroeder SA and Morris CD. (2010) Confronting a neglected epidemic: tobacco cessation for persons with mental illness and substance abuse problems. Ann Rev Public Health. 31: Schroeder & Morris, Annu Rev Public Health, 2010

Myths About Tobacco Use and Mental Illness
Tobacco is necessary self-medication for the mentally ill Nicotine does enhance concentration and attention, however this effect is short-lived and repeated exposure reduces the effect People with mental illness are not interested in quitting smoking About 70% of smokers with mental illness are interested in quitting Readiness to quit is unrelated to psychiatric diagnosis, severity of symptoms, or the coexistence of substance use Mentally ill people cannot quit smoking Studies have documented success in quitting in patients with depression, schizophrenia, PTSD, and substance use disorder Quitting smoking interferes with recovery from mental illness Quitting smoking does not exacerbate depression or PTSD symptoms, lead to psychiatric hospitalization, or increase use of alcohol or illicit drugs Smoking is the lowest priority concern for patients with acute psychiatric symptoms People with psychiatric disorders are more likely to die from tobacco-related disease than from mental illness Prochaska JJ Smoking and mental illness – Breaking the link. NEJM. 365 (3): Prochaska, NEJM, 2011

Smoking and Substance Use Disorder
Patients with substance use disorders (SUD) are 3-4 X as likely to use tobacco as individuals without SUD Tobacco-related diseases account for 50% of deaths among individuals treated for alcohol dependence (Hurt et al., 1996) Death rate 4-xs greater for cigarette smoking vs. nonsmoking long- term drug abusers (Hser et al., 2004) Health consequences of tobacco and other drug use synergistic: 50% greater than sum of each individually (Bien & Burge, 1990; Castellsague et al., 1999; Pelucchi et al., 2006) Among individuals treated for alcohol dependence, tobacco-related diseases were responsible for half of all deaths, greater than alcohol-related causes (Hurt & Offord 1996). In a 24-year study of long-term drug abusers, Hser et al. documented the death rate among cigarette smokers to be four times that of nonsmokers (Hser et al 2004, Hser et al 1994). The health consequences of tobacco and other drug use are synergistic and estimated to be 50% greater than the sum of each individually (Bien & Burge 1990). Bien TH, Burge R Smoking and drinking: a review of the literature. Int. J. Addict. 25: Hurt RD, Offord KP, Croghan IT, et al. Mortality following inpatient addictions treatment. Role of tobacco use in a community-based cohort. JAMA. Apr ;275(14): Hser YI, Gelbert L, Hoffman V, Grella CE, McCarthy W, Anglin MD Health conditions among aging narcotics addicts: Medical Examination Results. J. Behav. Med. 27: Hser YI, McCarthy WJ, Anglin MD Tobacco use as a distal predictor of mortality among long-term narcotics addicts. Prev. Med. 23: 61-9 Castellsague, X., Munoz, N., De Stefani, E., Victora, C.G., Catelletto, R., Rolon, P.A., Quintana, M.J., Independent and joint effects of tobacco smoking and alcohol drinking on the risk of esophageal cancer in men and women. Internat J Cancer, 82, 657−664. Pelucchi, C., Gallus, S., Garavello, W., Bosetti, C., La Vecchia, C., Cancer risk associated with alcohol and tobacco use: Focus on upper aero-digestive tract and liver. Alcohol Res Health, 29, 193−198.

Smoking and Substance Use Disorder
Over 75% of alcohol- and drug-dependent individuals in early recovery smoke About 80% of cocaine users also smoke cigarettes More than 80% of opioid-dependent individuals smoke A survey of individuals in methadone maintenance treatment found 77% smoked and 80% were “somewhat” or “very” interested in quitting (Richter et al., 2001) David Kalman, Ph.D., Sandra Baker Morissette, Ph.D., and Tony P. George, M.D. Am J Addict. 2005; 14(2): 106–123. doi: / Co-Morbidity of Smoking in Patients with Psychiatric and Substance Use Disorders Am J Public Health Feb;91(2):296-9. Tobacco use and quit attempts among methadone maintenance clients. Richter KP, Gibson CA, Ahluwalia JS, Schmelzle KH. Kalman et al., 2005

Evidence that Smoking Cessation Improves Substance Use Outcomes
Smoking cessation predicts improved alcohol sobriety 12-month prospective study: patients who quit smoking less likely to be alcohol dependent and had a higher number of total days of abstinence from alcohol and illicit drugs than those that continued to smoke (Kohn et al., 2003) Meta-analysis: Smoking cessation interventions associated with 25% increased likelihood of long-term abstinence from alcohol and illicit drugs (Prochaska et al., 2004) From Prochaska, 2010, Drug and Alcohol Dependence

Summary: Tobacco Treatment for Substance Abusing Patients
In general: Smoking cessation does not adversely affect patients with substance use disorders Currently available interventions show some effectiveness, at least for the short-term Range of abstinence rates, with unknown determinants Disorder specific data may eventually allow better tailoring of treatments Example: Varenicline significantly reduces alcohol consumption in people who smoke (Mitchell et al., 2012) Roughly parallel to the findings in the literature on tobacco cessation treatment with psychiatric patients.

Research on Tobacco & Depression
Most of the research has been conducted with people with a history of major depressive disorder (MDD), in freestanding smoking clinics Greater tobacco abstinence with increased psychological support (Hall et al., 1994; Brown et al., 2001) Individuals with recurrent MDD may be especially helped by CBT—mood management approaches Individuals with a history of MDD may have more difficulty quitting and more severe withdrawal symptoms than those without MDD In the 1980s, research suggested that the prevalence of a history of depression, specifically major depressive disorder (MDD), was higher among participants entering smoking-treatment research clinics than in the general population. These data were derived from intake interviews, conducted primarily to screen out smokers with current depression from trials where the presence of psychiatric illness was an exclusionary criterion (Glassman et al. 1988, Hall et al. 1993). At the same time, data were emerging from population-based studies indicating that the rate of smoking was higher among depressed individuals than in those who were not depressed. These two converging sets of findings intrigued smoking-treatment researchers, most working in freestanding clinics that did not have the mental health staff coverage to support currently depressed patients. Because of this historical accident, most of the studies of depression and cigarette smoking were completed in individuals who were not acutely ill but who had histories of MDD. Data from these studies indicated that smokers with a history of depression have increased smoking-abstinence rates with more intensive treatment. Although increased treatment length and intensity generally increase abstinence rates, independent of diagnosis, the amount of increase appears differentially greater for smokers with a history of depression than those with no such history (Hall et al. 1994, 1996, 1998). There is also evidence that cognitive behavioral therapy (CBT) interventions are especially helpful to smokers with a history of depression, but only with smokers who have a history of recurrent episodes of MDD rather than a history of a single episode (Brown et al. 2001, Haas et al. 2004). The reason for this specificity is not clear. It is possible that a single episode of depression is a disorder that is qualitatively different from recurrent episodes. For example, a single episode could be brought on by life events, such as illness or loss, that are not detected in the assessment. It is also possible that individuals with recurrent episodes have, over their lifetimes, learned to use skills to manage depression, anger, irritability, and other poor moods, and findCBTto be consistent with their coping styles. For a review: Hall, S.M., & Prochaska, J.J. (2009). Treatment of smokers with co-occurring disorders: emphasis on integration in mental health and addiction treatment settings. Annual Review of Clinical Psychology, 5,

Treating Tobacco Dependence in Depressed Smokers
322 depressed smokers recruited from four outpatient psychiatry clinics Stepped Care Intervention Stage-based expert system counseling Nicotine patch 6 session individual counseling Brief Contact Control This is the first randomized controlled trial in the literature (N=322) testing the efficacy of treating tobacco dependence in smokers with current clinical depression. Targeted at smokers who enter clinic for treatment of depression, with or without an intention of changing smoking behavior Limited to MDD, minor depression, dysthymia Intervention compared to usual care The innovative stepped care intervention involved two steps. The first is computer assisted counseling based on a stages of change made. Addresses the precontemplation, contemplation and preparation stages of change. Provides personalized reports, tailored to stage of change, and to changes since last assessment. It is followed by an offer of NRT and 6 sessions of counseling for everyone who reaches the contemplation stage. Also, by an offer of bupropion for all who fail NRT. The control condition was a list of local referrals, and a self-help brochure. Hall SM, Tsoh JY, Prochaska JJ, Eisendrath S, Rossi JS, et al Treatment for cigarette smoking among depressed mental health outpatients: a randomized clinical trial. Am. J. Public Health 96:1808–14 Hall et al., Am J Public Health

Abstinence Rates by Treatment Condition
* * As hypothesized, the experimental intervention increased seven-day point-prevalence abstinence rates at months 12 (20% versus 13%) and 18 (25% versus 19%) over that obtained in the control condition. The quit rate of 25% at 18 months in the treatment condition mirrors that found with stage-based expert system interventions applied with the general population of unmotivated smokers (Prochaska et al. 2006c). Also, as hypothesized, the intervention made it more likely that heavy smokers would make a quit attempt but did not change the probability of a quit attempt for light smokers. A final hypothesis, that the innovative intervention would increase the probability of participants reporting a goal of total and complete abstinence, also was supported. Hall SM, Tsoh JY, Prochaska JJ, Eisendrath S, Rossi JS, et al Treatment for cigarette smoking among depressed mental health outpatients: a randomized clinical trial. Am. J. Public Health 96:1808–14 * p<.05 for group comparison

Depression Severity & Tobacco Treatment Outcome
NO RELATIONSHIP Depression severity, as measured by the Beck Depression Inventory-II, was unrelated to participants’ likelihood of quitting smoking Among intervention participants, depression severity was unrelated to their likelihood of accepting cessation counseling and nicotine patch One finding we did not expect—there was no relationship of depression severity to smoking treatment outcomes. Our measure of severity was the BDI-II. Depression severity was not related to quitting smoking Additionally, in the experimental group, depression severity wasn’t related to accepting our offer of NRT and counseling. The level of depression at study entrance did not predict smoking treatment outcome, suggesting that depressed patients with a range of severity can profitably be offered smoking-treatment services. Hall SM, Tsoh JY, Prochaska JJ, Eisendrath S, Rossi JS, et al Treatment for cigarette smoking among depressed mental health outpatients: a randomized clinical trial. Am. J. Public Health 96:1808–14

Depression is a remitting and relapsing disorder
Does Abstinence from Tobacco Cause Recurrence of Psychiatric Disorders? Case studies suggesting major depressive episode (MDE) recurrence after quitting smoking among those with a history of depression Glassman, 2001: MDE recurrence in 6% (n=2) of those smoking vs. 31% (n=13) of those abstinent Differential loss to follow-up: 5% (n= 2/44) of quitters missing vs. 39% (n= 22/56) of continued smokers Tsoh, 2001: N=308, no difference in rate of MDE among abstinent vs. smoking participants Difference in rate of MDE by depression history: 10% among those with no MDD history vs. 24% if MDD+ history An important part of treating smoking in these populations is the ongoing concern that smoking cessation may cause recurrence of the co-existing disorder. When anti-smoking regulations first came into effect in psychiatric institutions, there was concern that it would exacerbate the problems of inpatients. This was at a time when smoking was still considered only a ‘bad’ habit by many in the professions. We know now that is not the cause. Now, the questions are slightly different. There are case studies suggestion recurrence of depression after quitting smoking. But depression is a chronic relapsing disorder, so really can’t be argued that cessation was causative. There are also studies suggesting that depressed smokers, at least those with a history of depression, may report more withdrawal symptoms, especially mood related withdrawal symptoms upon quitting. There are only two studies in the literature that studied this question in fairly good sized samples. In one, there was no evidence of recurrence, but the overall incidence of depression in one year was high—14%--this is whether or not they had quit smoking. MDE occurrence did differ significantly by depression history, and was substantially higher among those with a history positive for MDD (24% recurrence) vs. those with no history of MDD (10%). In a second study, Glassman and colleagues found a higher rate of recurrence among those who were abstinent as opposed to those who continued smoking, but the drop out rates between the conditions were large, with many more smokers not reachable, so the incidence of depression may have been higher in that group than estimated, since studies of depression have generally reported low follow-up rates. Further research is needed! If there is a relationship between depression and smoking, it further supports the need for addressing tobacco use within mental health treatment settings. Tsoh et al., Development of major depression after treatment for smoking cessation. Am J Psychiatry;157(3): Glassman AH, Covey LS, Stetner F, Rivelli S Smoking cessation and the course of major depression: a follow-up study. Lancet 357:1129–32 Depression is a remitting and relapsing disorder

Mental Health Outcomes: Depressed Smokers Treated for Tobacco
Depressed patients who quit smoking: No increase in suicidality Quit: 0% vs Smoking: 1-4% No increase in psych hospitalization Quit: 0-1% vs. Smoking: 2-3% Comparable improvement in % of days with emotional problems No difference in use of marijuana, stimulants or opiates Less alcohol use among those who quit smoking Prochaska et al. analyzed data from a randomized trial of 322 actively depressed smokers and examined the effect of smoking cessation on their mental health functioning. Only 1 of 10 measures at 4 follow-up time points was significant: participants who successfully stopped smoking reported less alcohol use than did participants who continued smoking. Depressive symptoms declined significantly over time for participants who stopped smoking and those who continued smoking; there were no group differences. Individuals in treatment for clinical depression can be helped to stop smoking without adversely affecting their mental health functioning. (Am J Public Health. 2008;98:446–448. doi: /AJPH ) Prochaska et al., 2008, Am J Public Health

Smoking and Schizophrenia – Impact on Functioning
Patients with schizophrenia who smoke, when compared to those who do not smoke, are likely to have higher rates of hospitalization, higher medication doses, and more severe psychiatric symptoms (Prochaska, 2011, NEJM) Study of outpatients with schizophrenia estimated the monthly costs of cigarettes to be approximately 27% of their monthly income (Steinberg, Williams, & Ziedonis, 2004)

Tobacco Cessation & Schizophrenia
Tobacco abstinence (1-wk) not associated with worsening of: Attention, verbal learning/memory, working memory, or executive function/inhibition, or clinical symptoms of schizophrenia (Evins et al., 2005) Bupropion: decreased the negative symptoms of schizophrenia (Evins et al. 2005, George et al. 2002) Varenicline: no worsening of clinical symptoms and a trend toward improved cognitive function (Evins et al., 2009) Treatments tailored for smokers with schizophrenia have the same efficacy as standard programs (George et al., 2000) Atypical antipsychotics associated with greater cessation than typical antipsychotics Two small randomized trials that used bupropion as a treatment adjunct indicated that bupropion had positive effects on treatment outcome and also decreased the negative symptoms of schizophrenia (Evins et al. 2005, George et al. 2002). George et al. (2002) reported that use of atypical antipsychotics increased responsiveness to bupropion as a smoking-cessation adjunct. Furthermore, Addington et al. (1998) used nicotine patches along with group treatment and found no evidence of worsening of schizophrenic symptoms. Thus, it appears that smoking cessation does not result in an exacerbation of schizophrenia symptoms, and that medications commonly used to treat tobacco dependence—NRT, and especially bupropion—may have mildly positive effects on the symptoms of schizophrenia. The smoking-cessation practice guidelines were updated in 2008 (Fiore 2008). They now include an emphasis on the need for practitioners to treat smokers with mental health and substance abuse diagnoses. The updated guidelines note that some data suggest that bupropion and nicotine replacement therapy (NRT) may improve negative symptoms of schizophrenia, and that individuals on atypical antipsychotic drugs may be more responsive to bupropion are than those on traditional antipsychotic medication. Evins AE, Cather C, Deckersbach T, Freudenreich O, Culhane MA, et al A double-blind placebocontrolled trial of bupropion sustained-release for smoking cessation in schizophrenia. J. Clin. Psychopharmacol. 25:218–25 George TP, Vessicchio JC, Termine A, Bregartner TA, Feingold A, et al A placebo controlled trial of bupropion for smoking cessation in schizophrenia. Biol. Psychiatry 52:53–61 George et al., 2000: This small (N=45) randomized clinical trial evaluated a 10 session, specially tailored tobacco cessation group treatment for schizophrenia compared to a standard American Lung Association treatment, both combined with nicotine replacement. Quit rates were modest and did not differ by treatment group. However, participants in the study who were on atypical antipsychotic agents had significantly enhanced rates of smoking cessation (55.6% in the atypical agent group versus 22.2% in the typical group). Participants on risperidone and olanzapine had the highest quit rates. Note: patients were not randomized to typical vs. atypical medication.

Integrating Tobacco Treatment into PTSD Treatment
RCT with 943 smokers with PTSD at VA Medical Centers Integrated care (IC) Manualized treatment delivered by PTSD clinician and case manager (3-hr training) Behavioral counseling once a week for 5 weeks plus 3 follow-up sessions NRT, bupropion, varenicline Usual care (UC): referral to VA smoking cessation clinic Historically, it is very rare to address tobacco dependence within mental health settings. This is unfortunate, not only because these settings are well placed to address tobacco use (mental health clinicians have the appropriate skills, safe setting, availability of useful treatments), but also because there is evidence that it may be more successful than referral treatment, even if the referral treatment is available in the same setting. Very nice study by McFall et al. in 2010 with veterans with PTSD compared integrated care with usual care, which was referral to the VA smoking cessation clinic. The results are impressive (next slide). McFall M, Saxon AJ, Thompson CE, Yoshimoto D, Malte C, et al Improving the rates of quitting smoking for veterans with posttraumatic stress disorder. Am. J. Psychiatry 162:1311–19 McFall M, Saxon AJ, Malte C, Chow B, Bailey S, Baker DG, Beckham JC, Boardman KD, Carmody TP, Joseph AM, Smith MW, Shih M, Lu Y, Holodniy M, Lavori PW Integrating tobacco cessation into mental health care for posttraumatic stress disorder. JAMA. 304 (22): McFall et al. JAMA, 2010 87

Integrating Tobacco Cessation into PTSD Treatment
More successful than referring patients to smoking cessation clinic Integrated care doubled prolonged abstinence compared to referral to smoking cessation clinic Bioverified point prevalence (by urine cotinine, a nicotine metabolite, measurement) may be lower than self-report since many patients have common environmental exposure to secondhand smoke (e.g., living with smokers, working in environment where exposed to secondhand smoke) McFall et al. JAMA, 2010

Smoking & Bipolar Disorder
Very little research has been done on patients with bipolar disorder who smoke. An online survey of ever smokers with bipolar disorder found: 48% of current smokers reported smoking to treat their MI Less than one-third reported that their MH provider encouraged them to quit smoking, some reported discouragement 74% of current smokers want to quit Intention to quit was not related to current mental health symptoms Ex-smokers reported better mental health than current smokers Possible concerns for bipolar patients: Renal clearance of varenicline in patients with compromised kidney function due to chronic lithium use Potential for bupropion to precipitate a manic episode Clinical trials of these medications are needed in patients with bipolar disorder who smoke Prochaska JJ, Reyes RS, Schroeder SA, Daniels AS, Doederlein A, Bergeson B An online survey of tobacco use, intentions to quit, and cessation strategies among people living with bipolar disorder. Bipolar Disorder. 13(5-6): Prochaska et al., 2011

More Studies Needed Few studies on tobacco cessation in individuals with mental illness Most clinical trials exclude participants with mental illness CPG 2008 recommends future research on: Relative effectiveness and reach of different tobacco dependence medications and counseling strategies in patients with psychiatric comorbidity Effectiveness and impact of tobacco dependence treatments within the context of nontobacco chemical dependency treatments Importance and effectiveness of specialized assessment and tailored interventions Impact of stopping tobacco use on psychiatric disorders and their management The 2008 CPG included 8,700 tobacco control studies, yet fewer than 2 dozen randomized clinical trials on smokers with current psychiatric diagnoses have been conducted (Prochaska et al., 2011)

Recommendations for Treating Patients in MH and SUD Care
Overall, evidence-based smoking cessation treatments are effective for both patients with and without mental illness. Patients with mental illness or substance use disorder may have more severe nicotine addictions than the general population, and so may require more intensive treatment and intervention. Patients do not need to be free of mental health symptoms to quit smoking and should be supported if they express an interest in quitting. Patients with mental illness should be encouraged to use medications to quit smoking. They may need combination treatment, higher doses, and a longer duration of treatment than the general population. Additional monitoring by a psychiatrist may be necessary. Schroeder SA and Morris CD. (2010) Confronting a neglected epidemic: tobacco cessation for persons with mental illness and substance abuse problems. Ann Rev Public Health. 31:

GT is a 53 year old disabled veteran. He has smoked since he was 13 years old, currently 20 cigarettes per day, but as much as 40 per day in the past. His score on the Fagerström Test for Nicotine Dependence is 7, indicating very heavy dependence. He is diagnosed with PTSD, Depression and Alcohol Dependence in full sustained remission. GT reports that the only time he quit smoking was when incarcerated for 6 months, and he resumed immediately following release. He has several chronic medical conditions including type 2 diabetes, hypertension and early stages of emphysema. He currently lives in a hotel room that permits smoking, and describes that many of his neighbors smoke. He views smoking as an effective strategy for managing stress, and is unable to generate other coping strategies for stress management when asked. He’s currently contemplating quitting, but is quite ambivalent. Discussion: What intervention approach/strategies would be appropriate for GT? What are the key obstacles that might impede GT ‘s efforts at quitting smoking? What level of intervention would be most appropriate for GT? 1. What intervention approach/strategies would be appropriate for GT? Motivational approach with goal of moving him from contemplation to determination (decision to quit). Evaluate pros and cons of smoking and quitting. 2. What are the key obstacles that might impede GT ‘s efforts at quitting smoking? Reference to Clinical Guideline “variables associated with lower rates of abstinence” mental illness (PTSD, depression) high nicotine dependence (FTND=7) High stress (disabled, presume limited income and resources) Presence of smokers (neighbors smoke) 3. What level of intervention would be most appropriate for Mr. Smith? -given GT ‘s history (no prior quit attempts) and obstacles he is likely to require high intensity intervention including behavioral counseling and support along with medications. Long-term treatment may be required to facilitate successful quitting.

DR is a 38 year old veteran currently in outpatient treatment for substance use disorder. He has been abstinent from alcohol and drugs for 60 days but is smoking 15 cigarettes per day, and obtained a score of 5 on the FTND, indicating medium nicotine dependence. He resides in a recovery home where most of the residents are smokers (although smoking is not permitted inside the residence). He has previously quit smoking for extended periods of time (up to two years in the past), but returned to smoking in the context of alcohol and drug use. He has recently resumed exercising and voices a desire to adopt a healthy lifestyle that includes quitting smoking. Discussion: What strategies would you use to engage DR in an active cessation attempt? What questions would you ask DR to help plan his quit attempt? 1.What strategies would you use to engage DR in an active cessation attempt? -Provide information regarding smoking cessation for individuals with substance use disorders (no negative impact on sobriety, association of quitting smoking with better substance use outcomes); -Elicit reasons for quitting and commitment to quit (e.g., help set and plan quit date) 2. What questions would you ask DR to help plan his quit attempt? -DR has previously quit for long periods of time, so identifying what he perceived as helpful and effective during prior attempts will be useful (use of medications, behavioral strategies, sources of support, etc). -Help him identify obstacles in his current life and problem solve strategies for managing these (e.g., living in recovery home, stress associated with recovery process)

National VA Tobacco Cessation Resources
VHA Tobacco and Health intranet site also has additional information on policy and clinical resources that are available: vaww.publichealth.va.gov/smoking/index.asp Providers can contact the VHA Clinical Public Health Program for any questions at: Monthly VHA Tobacco Cessation Clinical Update Audio Conference Series that is supported by EES that provides CEUs. For information on this, please contact: VA Tobacco Cessation SharePoint site: vaww.portal.va.gov/sites/tobacco/default.aspx VHA Pharmacy Benefits Management: National VA tobacco cessation resources are listed on this slide.

Useful Links for VA information
VA Varenicline Prescribing Criteria: Recommendations for Use of Combination Therapy in Tobacco Use Cessation: vaww.publichealth.va.gov/docs/smoking/combo_NRT_recomm.pdf VA Tobacco Use Cessation Treatment Guidance; Medication options:

Additional Tobacco Cessation Resource
Collaboration with VA Clinical Public Health and DoD TRICARE Web-based resource: Self-management tools and resources Live chat services with a coach Community support forum and blog VHA posters and Veteran wallet cards distributed to facilities and stocked in VA Forms Depot Available online at: vaww.publichealth.va.gov/smoking/clinical.asp

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