1. Substance Misuse Smoking Cessation Pilot: Implementation and Interim Findings Dr Gordon Morse – Medical Director Neesha Chand – Special Projects Manager

2. The need… (thanks to Lynda Bauld)

3. Smoking and substance misuse (APMS, 2007)

4. Smoking and Substance Misuse Smokers’ higher subjective symptoms of methadone inadequacy (Tacke et al, 2001) Smokers’ higher subjective symptoms of methadone inadequacy (Tacke et al, 2001) Smoking impedes cognitive recovery after alcohol abstinence (Kalman et al, 2010) Smoking impedes cognitive recovery after alcohol abstinence (Kalman et al, 2010) Smokers require higher doses of some benzodiazepines/opiates (RCP, 2013) Smokers require higher doses of some benzodiazepines/opiates (RCP, 2013)

5. Examples of health impacts Cohort study of 845 substance misuse patients in Minnesota, US: Cohort study of 845 substance misuse patients in Minnesota, US: 222 died during study 222 died during study 214 with death certificates: 51% documented a tobacco-related cause of death, > than proportion from alcohol & other drug-related causes (Hurt et al, 1996) 214 with death certificates: 51% documented a tobacco-related cause of death, > than proportion from alcohol & other drug-related causes (Hurt et al, 1996) Tobacco and alcohol use multiplies risk of developing cancers of upper respiratory & digestive tracts (Pelucchi et al, 2007; Kalman et al, 2010; Baca & Yahne, 2009) Tobacco and alcohol use multiplies risk of developing cancers of upper respiratory & digestive tracts (Pelucchi et al, 2007; Kalman et al, 2010; Baca & Yahne, 2009)

6. Staff and client attitudes Staff rated nicotine dependence treatment significantly less important than treatment of other substances Staff rated nicotine dependence treatment significantly less important than treatment of other substances 53% (n=88) staff thought addressing smoking should be put off until late or after a client’s primary addiction treatment & only 29% (n=40) thought it should be addressed early in treatment 53% (n=88) staff thought addressing smoking should be put off until late or after a client’s primary addiction treatment & only 29% (n=40) thought it should be addressed early in treatment By contrast, nearly half of clients thought it should be addressed early in treatment By contrast, nearly half of clients thought it should be addressed early in treatment Average rating of staff confidence in supporting someone who wanted to give up (on a 10 point scale) was 7.0 but varied considerably Average rating of staff confidence in supporting someone who wanted to give up (on a 10 point scale) was 7.0 but varied considerably

7. Treatment Smoking cessation doesn’t impact negatively on success of abstinence from other substances; may improve outcomes 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 (Prochaska et al, 2004) 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 (Prochaska et al, 2004) 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; Stuyt, 1997; 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; Stuyt, 1997; Weinberger & Sofuoglu 1997

8. Treatment Most studies demonstrate that adding smoking cessation therapy to substance abuse treatment programs yields higher overall drug and alcohol abstinence (Tsoh et al, 2011) Rationale: Discontinuance of one drug (nicotine) can support abstinence from other drugs due to shared neurobiological mechanisms (Baca & Yahne, 2009) However, smoking cessation programmes exclusively addressing tobacco are less effective for cannabis users (Stapleton et al, 2009)

9. Adverse Childhood Event (ACE) study - 1998 asked 26,000 consecutive adults coming through Kaiser Permanente’s Department of Preventive Medicine in San Diego, California if they would be interested in helping us understand how childhood events might affect adult health status. Seventy- one percent agreed (17,421) - mean age 57

10. ACE Scores: growing up in: a household where someone was in prison where the mother was treated violently with an alcoholic or a drug user where someone was chronically depressed, mentally ill, or suicidal where at least one biological parent was lost to the patient during childhood – regardless of cause recurrent physical abuse recurrent severe emotional abuse contact sexual abuse An individual exposed to none of the categories had an ACE Score of 0; an individual exposed to any four had an ACE Score of 4, etc.

11. Illicit Drug use

12. Licit Drug use - tobacco

14. NICE recommendations include:  Identifying people who smoke and offering and arranging support  Implement a comprehensive smoke free policy that includes the grounds  Support for staff smokers  Training for staff

15. Building on & sharing best practice  Turning Point, PHE, South London and Maudsley NHS Foundation Trust (SLAM)  National Centre for Smoking Cessation Training (NCSCT)  9 smoking cessation substance misuse service pilot sites  Share learning from the pilot that with other providers and commissioners considering introducing or expanding smoking cessation

16. Senior management steer Smoking Cessation Project Tiers SC Project Group: Jan Hernen (Clinical Psychologist), Neesha Chand (Project Lead), Darren Woodward (Project Sponsor) SC Working Group: Area Operation Managers (sign up to deliver action plan per pilot site) Smoking Cessation Leads: (operationally develop and deliver local action plans)

17. Methodology 1.benchmark service user smoking prevalence 2.benchmark workforce attitudes and behaviour 3.train & engage staff 4.review smoking policies 5.design interventions (assessment and goal planning) 6.record activity and outcomes 7.evaluate the pilots

18. 1. SU prevalence  TP benchmarking data extracted from April 2014 to February 2015 in the nine pilot areas for –SU smoking status (currently smoking, had previously smoked and had never smoked) –Data completeness or missing smoking status  Comparative data to be extracted after one year to test and demonstrate pilot outcomes

19. 2. Workforce attitudes & behaviour Team quiz & anonymous staff survey key findings Most staff are open to including brief advice on smoking cessation and signposting into treatment as part of their interventions Most staff already feel confident that they have the skills to support smokers to stop There is a high level of staff receptiveness to the idea of cessation

20. 3. Train & engage staff – consider timeline for launch

21. 4. Review smoking policies Service user and local service protocols – SUI Peer mentor and volunteer local protocols Staff – manager guidance documents – including breaks, e-cigarettes / vaping Staff wellbeing policies – improve direct access “Staff working in substance misuse services are about twice as likely to smoke as the general population. The desire by two thirds of them to stop is a good indication of a need for substance misuse services to put on ‘stop smoking’ services for their own staff.” Don Lavoie, PHE

22. 5. Design interventions  Develop in conjunction with staff  Consider how it will be recorded and monitored  Keep changes minimal – essential questions only for behaviour change and outcome measurements  Changes made to core TP paperwork –TP Assessment –NTA Goal Planner

23. Prompts – Assessment

24. Prompts – Recovery Planning

25. 6. Data recording  All activity & outcomes recorded on CIM (Client Information Management) System – inconsistent  Activity –Smoking Assessment –Interventions (VBA & specialist level 2/NRT) –Referrals (specialist level 2/NRT)  Outcomes –Outcome section in CIM –'Successful - No Longer Smoking‘ (new field)

26. 7. Interim findings  Activity has increased but recording is inconsistent  Where commissioned KPI’s in place uptake is higher  Mandatory fields would help with compliance – internal exception reporting required (TOPS)  Working groups and management steer is essential  September 2015 – pilot evaluation will include  Comparative data (Apr to Aug) improvements in identification and interventions  Sampling – assess impact of smoking cessation on substance misuse treatment outcomes

27. Pilot outcome  Integrated smoking cessation & substance misuse provision…  Improved access to smoking cessation for service users AND staff  Interventions being delivering internally and signposted to externally