Tobacco: Key Contributor to Early Death in Mental Health Stephen S. Michael, MS Director, ASHLine 2012 U.S. Public Health Service Scientific & Training Symposium Washington, DC June 20, :30 – 2:00 pm

Mental Illness in the U.S. Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-42, HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.

Serious Mental Illness in the U.S. Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-42, HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.

Treatment Services Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-42, HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.

Mental Illness & Mortality In the U.S. individuals with serious mental illness die, on average, 25 years prematurely. Suicide is NOT the most common reason for death.

Myths About Smoking & Mental Illness Tobacco is necessary self-medication (Tobacco industry has fostered this myth) They are not interested in quitting (Just as likely to want to quit as general population) They cannot quit (Tailored programs can have cessation rates similar to the general population) Quitting interferes with recovery from the mental illness (Research indicates this is not the case) It is a low priority problem (Smoking is a leading cause of death in behavioral health populations)

Factors Contributing to the Disparity Psychiatrists are less likely to ask about smoking, arrange follow-up, and refer to a quitline than other physicians. Behavioral health professionals are not usually trained in smoking cessation. Behavioral health treatment settings are often exempted from workplace smoking regulations. A recent in-depth study of eight drug treatment programs found that although a number of programs reported they offer counseling, pharmacotherapy, and other key components of evidence-based tobacco treatment, few actually provided any treatment and none did so systematically (Hunt et al., 2012).

Barriers To Tobacco Free lifestyles Lack of hope Failures and Fears Loneliness The Illness itself Lack of Skills & Knowledge & Support Poverty Low Expectations

Why??? “Where is the OUTRAGE?!” Dori Hutchinson, Sc.D – Director of Services Center for Psychiatric Rehabilitation Sargent College of Health and Rehabilitation Sciences Boston University

A Hidden Epidemic: Tobacco Use and Mental Illness Legacy ® – June 2011 –Issues of the high prevalence of tobacco use and nicotine dependence among people with mental illnesses. –Barriers to effective tobacco-cessation efforts to help people with mental illnesses quit. Education and training of mental health providers in evidence-based tobacco cessation Integration of tobacco prevention and cessation into mental health care

Prevalence of Psychiatric Disorders and Nicotine Dependence 22% of adults in US have a chronic mental illness and/or substance use disorder. Clients with mental illness have 2-4 times rates of nicotine dependence than the general population. Psychiatric populations represent 44-46% of the U.S. tobacco market, consume 34-44% of all cigarettes smoked, and spend up to 27-40% of their income on cigarettes. Lasser et al (2000); Kisely & Campbell (2008); Steinberg et al (2004); Schroeder & Morris (2010)

Smoking Prevalence among Adults by Lifetime Mental Illnesses Compared to General Population

Nicotine Dependence in Psychiatric Patients Individuals with schizophrenia are 3X more likely to be smokers, 50% are heavy smokers (> 25 cigarettes/d) and 13X more likely to smoke high-tar cigarettes than patients with other psychiatric disorders. Nicotine-dependent psychiatric patients have increased mortality from cardiovascular and respiratory disorders, lung cancer, infections, and diabetes. –Persons with mental illness die younger – 25 years earlier than the general population –20% shorter life span –Tobacco is the leading preventable cause of death Kisely & Campbell (2008); Schroeder & Morris (2010)

Psychiatric Comorbidity and Tobacco Use Individuals with mental illness have neurobiological causes that increase their tendency to use nicotine and other substances and make it more difficult to quit. –Addiction, dependence, and tolerance –Self-medication of nicotine withdrawal Nicotine may: –Enhance concentration, information processing, learning, and mood –Reduce medication side effects –Exacerbate comorbid psychiatric conditions –Act as a gateway drug to cocaine (mice) - Levine et al (2011)

Barriers for Tobacco Cessation Mental health professionals attitudes towards smoking –Treatment plans do not address nicotine dependence –In smoke-free psychiatric units – patients are frequently not offered nicotine replacement therapy –Only 1 out of 100 smokers (inpatient psychiatry) are encouraged to stop smoking or referred to a formal cessation program or provided NRT on discharge Psychiatrists are less likely to offer smoking cessation counseling/interventions than primary care physicians (12% vs 38%) Kisely & Campbell (2008)

Frequency of Smoking-Cessation Services Provided by Psychiatrists Compared to Those Provided by Family Physicians Source: American Association of Medical Colleges, Physician Behavior and Practice Patterns Related to Smoking Cessation

US Public Health Service Key Recommendations 1)Clinicians should strongly recommend the use of effective tobacco dependence counseling AND discuss medications with their patients who use tobacco 2) Health care systems, insurers, and purchasers should assist clinicians in making such effective treatments available Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. June 2008.

Tobacco Use and Dependence: 2008 Update All smokers with psychiatric disorders, including substance use disorders, should be offered tobacco dependence treatment. –Clinicians must overcome their reluctance to treat this population. Clinicians may wish to offer the tobacco dependence treatment when psychiatric symptoms are not severe. Stopping tobacco use may affect the pharmacokinetics of certain psychiatric medications. Stopping smoking or nicotine withdrawal may exacerbate a patient’s comorbid condition. DHHS Tobacco Use and Dependence 2008 Update, p

Tobacco Use and Dependence: 2008 Update Antidepressants (i.e. bupropion SR, nortriptyline) are effective in increasing the long term cessation rates in smokers with a past history of depression (when coupled with intensive psychosocial interventions). Bupropion SR and NRT may be effective for treating smoking in persons with schizophrenia and may improve negative symptoms of schizophrenia and depression. DHHS Tobacco Use and Dependence 2008 Update, p.146.

Treatment Approaches Brief interventions Motivational enhancement therapy Medications for tobacco cessation Nicotine replacement (gum, lozenge, patch, nasal spray, oral inhaler) Non-nicotine: bupropion, varenicline (FDA approved) Second-line non-nicotine: clonidine, nortriptyline (non-FDA approved) Non-drug therapies Individual based Cognitive behavioral therapy (CBT) Smokers Helpline – Coaching and Support Group based: peer-to-peer, self-help Community based Program based (e.g., smoke-free units)

Importance of Counseling Smokers with drug, alcohol or mental disorders are more likely to quit smoking if they receive counseling/coaching Healthy habits for living longer –Stopping smoking –Drinking alcohol moderately –Reducing caffeine intake –Exercising regularly –Eating a healthy diet –Stress reduction –Decreased risk for medical and psychiatric disorders –Lower mortality rates

Treatment Considerations: Recognize Different Modes of Intervention Inpatient/Residential (onsite cessation interventions) Intensive Treatment Settings (onsite cessation interventions with quitline support) Outpatient Treatment Settings (quitline cessation) Case Management/Medication Management (quitline cessation)

Why Include a Quitline? Feds Require every State to have one: QUITNOW Because they WORK!

Example: ASHLine (Comprehensive) Inbound telephone calls answered by tobacco coaches Self-help (mail & web) Proactive, multi-call program Medication assistance

Messages to Providers (Recovery Agents) Tobacco Cessation is a treatment issue, not a lifestyle choice. You don’t allow people to drink or use illicit drugs on campus, why tobacco? People with mental health challenges REALLY DO want to quit tobacco.

ASHLine Mission “Improve the health of Arizonans by providing client- centered tobacco cessation services through technology based interventions.”

Integrating Tobacco Treatment Legacy Smoking Cessation for Persons with Mental Illness: A Toolkit for Mental Health Providers Tobacco-Free Living in Psychiatric Settings: A Best- Practices Toolkit Promoting Wellness and Recovery UCSF – Education and Training

Schizophrenia and Smoking 2X risk of cardiovascular mortality 3X risk for respiratory disease and lung cancer Risk factors for morbidity/mortality: –Obesity, poor nutrition, sedentary lifestyle, poor health care Heavy smokers vs. light smokers –More positive symptoms and less negative symptoms –Fewer EPS symptoms –Increased substance abuse –More frequent hospitalizations –Increased suicide risk –Increased risk of polydipsia Aguilar et al (2005); Ziedonis et al (1994, 2008)

Alcoholics and Smoking 10 times greater risk of pancreatitis than non-smokers 3 times greater risk of cirrhosis 38 times greater risk of developing mouth and throat cancer than non-smokers and non-drinkers Chronic cigarette smoking increases the severity of brain damage associated with alcohol dependence

Bipolar Patients and Smoking Many patients with bipolar disorder report smoking to help treat the symptoms of mental illness. Most want to quit smoking and many are actively planning or trying to quit smoking. Few are advised to quit smoking by a mental health provider. Most have made multiple attempts to quit, many unaided with cessation medications or counseling. Quitting smoking is associated with mental health recovery. Prochaska et al (2011) – online survey

Substance Abuse and Smoking  75% of people (> 12 yrs) in substance abuse treatment smoke cigarettes Substance Abuse and Mental Health Services Administration: Smoking cessation interventions and treatment –25% increase in long-term abstinence from alcohol and illicit drugs –Incorporating smoking cessation into treatment for alcohol and drug abuse does not jeopardize recovery –Eliminating tobacco use is associated with decreased use of other abused substances (12 studies) Prochaska et al (2004); Baca & Yahne (2009)

Thank You Arizona Smokers’ Helpline (ASHLine) Zuckerman College of Public Health University of Arizona Stephen S. Michael, MS (520)