1. Smoking and Substance Misuse Slides by Ann McNeill, Luke Mitcheson and Gay Sutherland Institute of Psychiatry, KCL

2. Summary Relationship between smoking and substance misuse and treatment Relationship between smoking and substance misuse and treatment Local audits Local audits NICE guidance NICE guidance Next steps? Next steps?

3. n 3 million smokers in UK with a mental health disorder n No change in prevalence in last 20-30 yrs n “Moral imperative…” n “Radical changes needed”

4. Smoking Prevalence (%) Note: General Population includes all categories of mental illness

5. Healthcare Staff & Culture! n Psychiatrists have higher smoking rates than other medics and are less likely to treat nicotine addiction! n Believe MI smokers do not want to quit n Believe they can not quit n Believe quitting would negatively affect their mental state Wrong!

7. Smoking and substance misuse Largest cause of preventable death, disease & health inequalities in the UK High smoking prevalence previously demonstrated in substance misusers and interrelationship e.g. Smokers’ subjective symptoms of methadone inadequacy Smoking impedes cognitive recovery after alcohol abstinence Smokers require higher doses of some benozodiapines/opiates Tobacco/cannabis users made fewer attempts to quit and less likely to successfully quit than tobacco-only smokers

8. Mortality and morbidity Smoking may be responsible for much of the increased mortality of substance misusers compared with general pop. Eg. Smoking may be responsible for much of the increased mortality of substance misusers compared with general pop. Eg. Cohort study of 845 substance misusers in Minnesota Cohort study of 845 substance misusers in Minnesota 222 died during study 222 died during study 214 with death certificates: 51% = tobacco-related death, > than proportion from alcohol & other drug- related causes (Hurt et al, 1996) 214 with death certificates: 51% = tobacco-related death, > than proportion from alcohol & other drug- related causes (Hurt et al, 1996) Tobacco & alcohol use multiplies risk of developing cancers of upper respiratory & digestive tracts (Kalman et al, 2010; Baca & Yahne, 2009)

9. NICE recommendations include: Identifying people who smoke and offering and arranging support Identifying people who smoke and offering and arranging support Implementing a comprehensive smoke-free policy including the grounds Implementing a comprehensive smoke-free policy including the grounds Support for staff who smoke Support for staff who smoke Training for staff Training for staff

10. Treatment Smoking cessation does NOT impact negatively on success of abstinence from other substances; may improve outcomes; continued nicotine dependence may be a risk factor for relapse Smoking cessation does NOT impact negatively on success of abstinence from other substances; may improve outcomes; continued nicotine dependence may be a risk factor for relapse Meta-analysis of 19 RCTs of smoking-cessation interventions for people in substance misuse treatment and in recovery showed concurrent treatment of smoking resulted in a 25% increased likelihood of long- term abstinence from alcohol and illicit drugs Meta-analysis of 19 RCTs of smoking-cessation interventions for people in substance misuse treatment and in recovery showed concurrent treatment of smoking resulted in a 25% increased likelihood of long- term abstinence from alcohol and illicit drugs Khara & Okoli, 2011; Burling et al, 2001; Kalman et al, 2010; Baca & Yahne 2009; Williams & Ziedonis, 2004; Prochaska et al, 2004; Stapleton et al, 2009; Goulay et al, 1994; Moore & Budney, 2001; Prochaska et al, 2004

11. Treatment Smoking cessation programmes exclusively addressing tobacco less effective for cannabis users

12. SLaM audits Audit of all computerised client records across SLaM since 2008 for smoking status recording, prevalence and offer of support Audit of all computerised client records across SLaM since 2008 for smoking status recording, prevalence and offer of support Audit of addiction wards and community services in SlaM in 2012-3 Audit of addiction wards and community services in SlaM in 2012-3

13. DiagnosisN Smoking Status Recorded Smokers 20-22% General Pop. Received advice to quit Received referral to smoking service Depression F32/33 26,82812% (3,221) 34% (1,103) 72% (796)13% (141) Personality Disorders F60/61 4,62122% (1,023) 64% (659) 76% (501)17% (115) Serious Mental Illness F20/25/31 15,95433% (5,359) 54% (2,909) 83% (2,439)22% (656) Opiate use6,49126% (1,700) 89% (1,524) 71% (1,088)7.4% (113) Alcohol use11,15815% (1,730)77% (1,335) 67% (906)7.4% (129)

14. DiagnosisN Smoking Status Recorded Smokers 20-22% General Pop. Received advice to quit Received referral to smoking service Depression F32/33 26,82812% (3,221) 34% (1,103) 72% (796)13% (141) Personality Disorders F60/61 4,62122% (1,023) 64% (659) 76% (501)17% (115) Serious Mental Illness F20/25/31 15,95433% (5,359) 54% (2,909) 83% (2,439)22% (656) Opiate use6,49126% (1,700) 89% (1,524) 71% (1,088)7.4% (113) Alcohol use11,15815% (1,730)77% (1,335) 67% (906)7.4% (129)

15. DiagnosisN Smoking Status Recorded Smokers 20-22% General Pop. Received advice to quit Received referral to smoking service Depression F32/33 26,82812% (3,221) 34% (1,103) 72% (796)13% (141) Personality Disorders F60/61 4,62122% (1,023) 64% (659) 76% (501)17% (115) Serious Mental Illness F20/25/31 15,95433% (5,359) 54% (2,909) 83% (2,439)22% (656) Opiate use6,49126% (1,700) 89% (1,524) 71% (1,088)7.4% (113) Alcohol use11,15815% (1,730)77% (1,335) 67% (906)7.4% (129)

16. SLaM audits Audit of all computerised client records across SLaM since 2008 for smoking status recording, prevalence and offer of support Audit of all computerised client records across SLaM since 2008 for smoking status recording, prevalence and offer of support Audit of addiction wards and community services in SlaM in 2012-3 Audit of addiction wards and community services in SlaM in 2012-3

17. Smoking Audit: Method Questionnaire survey conducted across Addiction services in or connected to SLaM Questionnaire survey conducted across Addiction services in or connected to SLaM (Blackfriars, Lantern Hall, Beresford Project, Lorraine Hewitt House, AAU, Clouds House, and Ley Community) Staff and client questionnaires to measure: Staff and client questionnaires to measure: smoking behaviour smoking behaviour motivation to quit motivation to quit treatment provision treatment provision attitudes towards nicotine dependence treatment attitudes towards nicotine dependence treatment 97% (n=145) and 85% (n=163) response rates for staff and clients respectively. 97% (n=145) and 85% (n=163) response rates for staff and clients respectively.

18. Key Findings: 1. High smoking prevalence StaffClients Ever smoked 70% (n= 102) 94% (n= 154) Currently smoking45% (n= 65) 88% (n= 144) General Pop. = 20%

19. (2) Motivated client group 81% of clients who smoked wanted to give up 81% of clients who smoked wanted to give up 23% wanted to in next 3 months 23% wanted to in next 3 months 46% wanted to talk to someone about reducing harmfulness of their smoking; 21% did not know 46% wanted to talk to someone about reducing harmfulness of their smoking; 21% did not know 53% wanted advice on stopping abruptly 53% wanted advice on stopping abruptly 77% wanted advice on gradually reducing no. of cigs smoked 77% wanted advice on gradually reducing no. of cigs smoked 87% wanted info on NRT 87% wanted info on NRT >2/3 rd of clients did not know enough about varenicline (Champix) or bupropion (Zyban) to express any interest >2/3 rd of clients did not know enough about varenicline (Champix) or bupropion (Zyban) to express any interest

20. 3. A Lack of Treatment Provision Only 15% clients who smoked had been offered support during current treatment episode Only 15% clients who smoked had been offered support during current treatment episode 56% had never been offered support 56% had never been offered support Huge unmet clinical challenge

21. 4. Staff and Client Attitudes Staff rated nic add. treatment significantly less important than treatment of other substances Staff rated nic add. treatment significantly less important than treatment of other substances 53% staff thought addressing smoking should be put off until late or after a client’s primary addiction treatment 53% staff thought addressing smoking should be put off until late or after a client’s primary addiction treatment Only 29% thought it should be addressed early in treatment Only 29% thought it should be addressed early in treatment But nearly half of clients thought it should be addressed early in treatment But nearly half of clients thought it should be addressed early in treatment Staff confidence rating for helping client who wanted to quit = 7 (10 point scale) but varied considerably Staff confidence rating for helping client who wanted to quit = 7 (10 point scale) but varied considerably

22. Steps being taken Assessing evidence on treatment of smoking and illicit drugs Assessing evidence on treatment of smoking and illicit drugs Improving recording and referrals in line with new SLaM systems Improving recording and referrals in line with new SLaM systems Reorientation of the Maudsley Specialist Smokers’ Clinic Reorientation of the Maudsley Specialist Smokers’ Clinic

23. Conclusions Strong relationship between smoking and use of other substances Strong relationship between smoking and use of other substances Motivation to stop is apparent but not being addressed Motivation to stop is apparent but not being addressed Need to treat substances concurrently (e.g. Becker et al, 2013) Need to treat substances concurrently (e.g. Becker et al, 2013) Staff who smoke more likely to question importance of tobacco treatment, so no. of staff smoking is a concern for their own and patients’ health Staff who smoke more likely to question importance of tobacco treatment, so no. of staff smoking is a concern for their own and patients’ health Introducing mandatory training and care pathways within SLaM to address concerns and also NICE guidance Introducing mandatory training and care pathways within SLaM to address concerns and also NICE guidance

25. Harm Reduction for Smoking? Nicotine is largely why people smoke Nicotine is largely why people smoke But it’s the other smoke constituents (CO, tar etc) that cause the death and disease But it’s the other smoke constituents (CO, tar etc) that cause the death and disease

26. Rationale for Harm Reduction: Nicotine Harm Continuum Most Dangerous Least Dangerous QUIT! E-cigs?NRT

27. What’s Needed? Develop clinical pathway to address the unmet clinical need: Develop clinical pathway to address the unmet clinical need: Mandatory recording of smoking status Mandatory recording of smoking status Development of routinely provided support which should be documented in case notes Development of routinely provided support which should be documented in case notes Signpost specialist services Signpost specialist services NRT for withdrawal relief available to in- patients NRT for withdrawal relief available to in- patients

28. Clinically Significant Interactions with Tobacco Antidepressants Amitriptyline Nortriptyline Imipramine Clomipramine Fluvoxamine Trazodone Antipsychotics Clozapine Fluphenazine Haloperidol Olanzapine Chlorpromazine

29. Other Clinically Significant Interactions with Tobacco n Heparin n Insulin n Warfarin n Theophylline n Propranolol n Tacrine n Acetaminophen n Caffeine

30. Recording and Monitoring

31. What’s needed? Develop clinical pathway to address the unmet clinical need Develop clinical pathway to address the unmet clinical need Staff training: Staff training: Support for staff smokers: Support for staff smokers: We are doing some qualitative research with staff to explore high levels of occasional smoking further We are doing some qualitative research with staff to explore high levels of occasional smoking further

32. What Can be Done Locally? Promote discussion around how your service can encourage and support smoking cessation Promote discussion around how your service can encourage and support smoking cessation Identify a smoking “champion” on the ward/service Identify a smoking “champion” on the ward/service Routinely ask and record clients’ smoking status and motivation to quit Routinely ask and record clients’ smoking status and motivation to quit Inform clients about pharmacological and behavioural support available as part of standard care and consider harm reduction for smokers who cannot or will not stop Inform clients about pharmacological and behavioural support available as part of standard care and consider harm reduction for smokers who cannot or will not stop Identify where clients and staff can get support and clearly signpost this Identify where clients and staff can get support and clearly signpost this Encourage staff to complete relevant training (mandatory?) Encourage staff to complete relevant training (mandatory?)

33. Acknowledgements Camilla Cookson Camilla Cookson All colleagues in the services in SLaM who supported the audit All colleagues in the services in SLaM who supported the audit Karolina Bogdanowicz Karolina Bogdanowicz Prof John Strang Prof John Strang Dr Elena Ratschen Dr Elena Ratschen