1. Addressing Tobacco Use in Mental Health Settings Overview Materials Prepared By: Center for a Tobacco-Free Finger Lakes University of Rochester School of Medicine & Dentistry Department of Public Health Sciences (The information, contained in these slides, is current as of April 2015) 1

2. Don’t be Silent About Smoking 70% of smokers want to quit. 7% of smokers achieve long-term abstinence on their own. With physician assistance - every patient, every visit - this increases to > 30%.

3. 3 Smoking Cessation Approaches At all patient contacts Ask whether patient smokes Advise patient to stop Assess whether patient wants to take action Assist patient in developing plan Arrange follow-up Primary Care ModelPerson Centered Approach Facilitator- Educator Group/Individual Treatment Model Facilitator takes an active role in leading group process and leading discussion Express Empathy by using reflective listening Avoid being overly directive: assume that the client is responsible for the decision to change Support self-efficacy and optimism for change Emmons, K. M., & Rollnick, S. (2001). Motivational interviewing in health care settings: opportunities and limitations. American journal of preventive medicine, 20(1), 68-74.

4. Why Should We Become Involved? Saves lives – and Saves healthcare dollars Nicotine Dependence is a disorder ( Diagnostic and Statistical Manual [DSM-V] of the American Psychiatric Association ) Disproportionately high in the mental health population Tobacco dependence and mental illness are co-occurring Tobacco interferes with psychiatric medications Cessation treatment is consistent with wellness and recovery approaches Source: Williams and Zeidonis, 2006

5. Mental Illness Disparities Research suggests that smoking prevalence among U.S. adults with mental illness or serious psychological distress ranges from 34.3% (phobias or fears) to 88% (schizophrenia), compared with 18.3% among adults with no such illness. The nature of these disorders increases vulnerability to initiation and maintenance of smoking behaviors. Centers for Disease Control and Prevention (CDC) Vital Signs: Current Cigarette Smoking Among Adults Aged ≥18 Years with Mental Illness — United States, 2009–2011. MMWR Morbidity and Mortality Weekly Report, February 8, 2013 / 62(05);81-87 Kalman, Morissete and George, 2005. Am. J. Addictions. 14: 106-123

6. Mental Illness Disparities Up to 25% of disability income may be spent by heavily- dependent mentally ill smokers on tobacco products each month (Ziedonis et al., 2005) While nicotine-dependent mentally ill smokers make up 7.1% of the population of smokers, they consume 34.7% of all cigarettes (Grant et al., 2004) Cessation rates in SPMI (e.g. schizophrenia, bipolar, PTSD) are 1/2 to 1/3 of those in the general population. Hitsman, B et al., 2009. Can. J. Psychiatry Tony P. George, M.D., FRCPC Tobacco Treatment in People with Serious Mental Illness: The Devil is in the Details!

7. Support Clients The greatest chance the clinician has to aid the clients who do not want to stop smoking at the present, but are open to consider quitting at some point in the future, is to not pressure them, while letting them know you are always willing to help if they ever decide differently. Miller, G., Armon, T., & Bucciferro, D. The Role of Mental Health Professionals in Tobacco Dependence Treatment [PowerPoint Presentation]. Retrieved from http://www.nysmokefree.com/confcalls/Prevcalls.aspx

8. Treatment of Tobacco Dependence in People with Mental Health Dx Need to combine medications with behavioral therapies Need to integrate tobacco dependence treatments into psychiatric settings e.g., policy, system-wide strategies, programmatic elements, treatment plans, treatment team meetings Hitsman, B et al., 2009. Can. J. Psychiatry Tony P. George, M.D., FRCPC Tobacco Treatment in People with Serious Mental Illness: The Devil is in the Details!

9. Improved Substance Abuse Recovery Rates Alcoholics who quit smoking were more likely to maintain long term abstinence. Bobo et al, 1987; 1989 Sees & Clark, 1993 Alcoholics who quit smoking were less likely to relapse to drinking. MA Med Society, 1997 Strong Associations between tobacco & opiate and cocaine use. Frosch et al. 2000 Source: Jill Williams, “Treating Tobacco Dependency in Mental Health Settings”

10. Co-Occurring Substance Abuse Recovery is Enhanced Long Term A meta-analysis completed by Prochaska et al. (2004a) indicated that providing smoking cessation interventions did not impede abstinence from alcohol and illicit drugs. Post-treatment non-nicotine substance-use abstinence rates were 52% in the smoking cessation group and 54% in the comparison condition (NOT Statistically Significant). Long-term follow-up: non-nicotine abstinence rates were 37% in the smoking cessation group and 31% in the comparison conditions (slight but significant increase in the likelihood of abstinence from drugs and alcohol among patients receiving a smoking-cessation intervention relative to patients in the control condition). Source: Sharon M. Hall and Judith J. Prochaska (2009). Treatment of Smokers with Co-Occurring Disorders: Emphasis on Integration in Mental Health and Addiction Treatment Settings. Annu Rev Clin Psychol. 2009 ; 5: 409–431.

11. Wellness and Health Education Interventions should address both patients’ misconceptions regarding tobacco use and realistic fears about quitting, including: Nicotine withdrawal Relapse of mental illness Weight gain  People with SMI are have elevated risk for metabolic syndrome Crucial to focus on healthier lifestyle, including good nutrition and exercise, simultaneously with tobacco cessation. Miller, G., Armon, T., & Bucciferro, D. The Role of Mental Health Professionals in Tobacco Dependence Treatment [PowerPoint Presentation]. Retrieved from http://www.nysmokefree.com/confcalls/Prevcalls.aspxhttp://www.nysmokefree.com/confcalls/Prevcalls.aspx

12. Chemicals in Tobacco Smoke Butane – lighter fluid Cadmium – batteries Toluene – solvent Ammonia – cleaner Acetic acid – vinegar Methane – sewer gas Arsenic – Poison Carbon Monoxide – poisonous gas Methanol – rocket fuel Formaldehyde – embalming fluid Click http://www.nysmokefree.com/subpage.aspx?p=40&p1=4020 for additional information.http://www.nysmokefree.com/subpage.aspx?p=40&p1=4020

13. Timing of Health Benefits 1990 Surgeon General’s Report 20 minutes Blood pressure, heart rate return to normal 8 hours O 2 level returns to normal; nicotine and CO levels reduced by half 24 hours CO is eliminated from body; lungs begin to eliminate mucus, debris 48 hours Nicotine eliminated from body; taste and smell improve 72 hours Breathing is easier; bronchial tubes relax; energy levels increase 2 to 12 weeks Circulation improves 3 to 9 months Lung function increases by up to 10%; coughing, wheezing, breathing problems reduced 1 year Heart attack risk halved 10 years Lung cancer risk halved 15 years Heart attack risk same as for someone who never smoked