Smoking Cessation in Mental Health and Primary Care Practice

13th Annual Statewide Integrated Care Conference

Integrating Substance Use, Mental Health, and Primary Care Services: Courageous and Compassionate Care

10/19/2016

Steven A. Schroeder, MDDistinguished Professor of Health and Health CareDepartment of Medicine, UCSFDirector, Smoking Cessation Leadership Center

Disclosure

Dr. Steven Schroeder does not have relevant financial relationships with commercial interests.

The Health Consequences of Smoking:

50 Years of ProgressA Report of the Surgeon General

1964 2014

50 Years of Tobacco ControlJAMA

It’s a New Era

Tobacco’s Deadly Toll

540,000 deaths in the U.S. each year*

4.8 million deaths world wide each year

--Current trends show >8 million deaths annually by 2030

42,000 deaths in the U.S. due to second-hand smoke exposure

14 million in U.S. with smoking related diseases (60% with COPD)

42.1 million smokers in U.S. (76.9% daily smokers, averaging 14.2 cigarettes/day, 2013)

* Carter et al, NEJM, Feb 12, 2015

TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2014

18.8%

14.8%

Trends in cigarette current smoking among persons aged 18 or older

Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2014

NHIS. Estimates since 1992 include some-day smoking.

* 2015 early NHIS data

68.9% want to quit

15.1% of adults are

current smokers

Male

0

10

20

30

40

50

60

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

Female

Pe

rce

nt

Male

Female

Smoking Prevalence and Average Number of Cigarettes Smoked per Day per Current Smoker 1965-2010

*January-March 2015: 15.3% prevalence!

Per

cen

t/N

um

ber

of

Cig

aret

tes

Sm

oke

d D

aily

Source: Schroeder, JAMA 2012; 308:1586; *CDC/NCHS, National Health Interview Survey, 1997-March 2015, Sample Adult Core

20

85

4329 17

365

0

50

100

150

200

250

300

350

400

450

Behavioral Causes of Annual Deaths in

the United States, 2000

Source: Mokdad et al. JAMA 2004;291:1238-1245; Mokdad et al. JAMA. 2005; 293:293

Flegal KM, Graubard BI, Williamson DF, Gail, MH. Excess deaths associated with

underweight, overweight, and obesity. JAMA 2005;293:1861-1867

Sexual Alcohol Motor Guns Drug Obesity/ Smoking

Behavior Vehicle Induced Inactivity

Also suffer from mental

illness and/or substance

abuse

*

435

112

*

Health Consequences of Smoking

U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General, 2010.

Cancers

• Acute myeloid leukemia

• Bladder and kidney

• Cervical

• Colon, liver, pancreas

• Esophageal

• Gastric

• Laryngeal

• Lung

• Oral cavity and pharyngeal

• Prostate (↓survival)

Pulmonary diseases

• Acute (e.g., pneumonia)

• Chronic (e.g., COPD)

• Tuberculosis

Cardiovascular diseases

• Abdominal aortic aneurysm

• Coronary heart disease

• Cerebro-vascular disease

• Peripheral arterial disease

• Type 2 diabetes mellitus

Reproductive effects

• Reduced fertility in women

• Poor pregnancy outcomes (ectopic pregnancy,

congenital anomalies, low birth weight, preterm

delivery)

• Infant mortality; childhood obesity

Other effects: cataract; osteoporosis; Crohns;

periodontitis,; poor surgical outcomes;

Alzheimers; rheumatoid arthritis; less sleep

Causal Associations with Second-hand Smoke

Developmental

– Low birthweight

– Sudden infant death syndrome

(SIDS)

– Pre-term delivery

-- Childhood depression

Respiratory

– Asthma induction and

exacerbation

– Eye and nasal irritation

– Bronchitis, pneumonia, otitis

media, bruxism in children

– Decreased hearing in teens

Carcinogenic

– Lung cancer

– Nasal sinus cancer

– Breast cancer? (younger,

premenopausal women)

Cardiovascular

– Heart disease mortality

– Acute and chronic coronary heart

disease morbidity

– Altered vascular properties

USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General.

There is no

safe level of

second-hand

smoke.

The Toll from Smoking: An Apparent ParadoxAs prevalence declines, toll increases

Reason is increased appreciation of damage caused by smoking, esp. COPD

Estimates of annual deaths and morbidity should soon plateau and then fall, but still at very high rate of damage

Smoking and Behavioral Health: The Heavy Burden

200,000 annual deaths from smoking occur among patients with CMI and/or substance abuse

This population consumes 40% of all cigarettes sold in the United States

-- higher prevalence

-- smoke more

-- more likely to smoke down to the butt

People with CMI die earlier than others, and smoking is a large contributor to that early mortality

Greater risk for nicotine withdrawal

Social isolation from smoking compounds the social stigma

Vulnerable Populations

Higher smoking rates have persisted among:

Individuals with mental and/or SU disorders (38%)

The poor (below poverty level: 29%; Medicaid: 37%)

Least educated (GED: 41%; Less than H.S.: 24%)

LGBT persons (27%)

Chronically homeless (80%)

Incarcerated persons (70% – 83%)

HIV infected (50%)

Sources: http://cms.samhsa.gov/newsroom/press-announcements/201303200900

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Tobacco.html

http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm

Tsai & Rosenheck, Psychiatric Services, 2012; Parker et al., Addict Med, 2014.

Industry Targets BH population

Pushed Doral to homeless shelters, and psychiatric facilities

R .J. Reynolds &"consumer subcultures,“(gay/Castro)" and "street people”

Sub Culture Urban Marketing

Smoking Prevalence and Substance Abuse

53-91% of people in addiction treatment settings use tobacco (Guydish et al, Nicotine and Tobacco Research, June 2011, p 401)

Tobacco use causes more deaths than the alcohol or drug use bringing clients to treatment: death rates among tobacco users nearly 1.5 times the rate of death from other addiction-related causes (SAMHSA N-SSATS Report September

2013)

Stopping smoking increases odds of abstinence (SAMHSA N-

SSATS Report September 2013)

How Can You Help Smokers to Quit?

Nicotine enters

brain

Stimulation of

nicotine receptors

Dopamine release

Dopamine Reward Pathway

Prefrontal

cortex

Nucleus

accumbensVentral

tegmental

area

Nicotine Addiction

Tobacco users maintain a minimum serumnicotine concentration in order to

• Prevent withdrawal symptoms

• Maintain pleasure/arousal

• Modulate mood

Users self-titrate nicotine intake by

• Smoking more frequently

• Smoking more intensely

• Obstructing vents on low-nicotine brand cigarettes

Tools for Smoking Cessation

5A’s (Ask, Advise, Assess, Assist, Arrange)

AAR (Ask, Advise, Refer)

Quitlines

NRT and other medications

Counseling and behavioral change strategies

Peer-to-peer intervention

Responses to Patient Who Smokes

Unacceptable: “I don’t have time.”

Acceptable

• Refer to a quit line and/or web program

• Establish systems in your office and hospital

• Become a cessation expert

Tobacco Dependence Treatment

Persons with mental illnesses and substance use disorders benefit from same interventions as general population

Combination of counseling and pharmacotherapy should be used whenever possible

Duration of treatment might be longer

View failed quit attempt as a practice, not failure

TOBACCO DEPENDENCE:A 2-PART PROBLEM

Tobacco Dependence

Treatment should address the physiologic and the behavioral aspects of dependence.

Physiologic Behavioral

Treatment Treatment

The addiction to nicotine

Medications for cessation

The habit of using tobacco

Behavior change program

PHARMACOTHERAPY

Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update.

Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.

Medications significantly improve success rates.

* Includes pregnant women, smokeless tobacco users, light smokers, and adolescents.

“Clinicians should encourage all patients

attempting to quit to use effective

medications for tobacco dependence

treatment, except where contraindicated or

for specific populations* for which there is

insufficient evidence of effectiveness.”

Pharmacologic Methods: First-line Therapies*

Three general classes of FDA-approved medications for smoking cessation:

Nicotine replacement therapy (NRT)

-- nicotine gum, patch, lozenge, nasal spray, inhaler

Partial nicotine receptor agonist

-- varenicline

--? cytisine in the future

Psychotropics

-- sustained-release bupropion

* Counseling plus meds better than either alone

Currently, no medications have an FDA indication

for use in spit tobacco cessation.

Caveats About Cessation Literature

Smoking should be thought of as a chronic condition, yet drug treatment often short (12 weeks) in contrast to methadone maintenance

Great spectrum of severity and addiction; treatment should be tailored accordingly

Volunteers for studies likely to be more motivated to quit

Placebo and drug groups tend to have more intensive counseling than found in real practice world; and counseling is not a monolithic black box

Most drug trials exclude patients with mental illness

LONG-TERM (6 month) QUIT RATES for

AVAILABLE CESSATION MEDICATIONS

0

5

10

15

20

25

30

Nicotine gum Nicotine

patch

Nicotine

lozenge

Nicotine

nasal spray

Nicotine

inhaler

Bupropion Varenicline

Active drug

Placebo

Data adapted from Cahill et al. (2012). Cochrane Database Syst Rev; Stead et al. (2012).

Cochrane Database Syst Rev; Hughes et al. (2007). Cochrane Database Syst Rev

Perc

en

t q

uit

16.3 15.9

10.0 9.8

18.9

8.4

23.9

11.8

17.1

9.1

18.9

10.612.0

28.0

Financial Impact

People with mental illnesses and/or addictions may spend up to 1/3 their income on cigarettes*

A pack a day smoker spends on average…

$5.51** per day

$38.57 per week

$154.28 per month

$1,851.36 per year

$18,513.60 per 10 years

*Steinberg, 2004

**Average national price 2015 (American Lung Association)

Myths About Smoking and Behavioral Health

Tobacco is necessary self-medication (industry has supported this myth)

They are not interested in quitting (same % wish to quit as general population)

They can’t quit (quit rates same or slightly lower than general population)

Quitting worsens recovery from the mental illness (not so; and quitting increases sobriety for alcoholics)

It is a low priority problem (smoking is the biggest killer for those with mental illness or substance abuse issues)

Source: Prochaska, NEJM, July 21, 2011

Power of Peers

Peer-led support groups, community referrals, etc.

Train peers to integrate tobacco cessation & wellness services into existing roles and responsibilities.

“Embedded” model uses programs that have peer specialists on staff or as volunteers

New Cautions About Varenicline

In addition to older concerns about increased suicide risks (rare but possible causation) and cardiac rhythm problems (controversial)

New March 2015 warnings about potential for rare seizures and lower alcohol tolerance

2016 EAGLES Study Shows VareniclineSafety*

Large RCT, with 1026 psychiatric pts receiving varenicline

No increase in psychiatric symptoms, but much greater smoking cessation

FDA considering whether to retain black boxed warning, but

FDA reviewers currently questioning efficacy of EAGLES Study (not all adverse events noted)

2 FDA panels advise removing black boxed warning for neuropsychiatric risks (September 2016)

* Anthenelli et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in

smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled

clinical trial. Lancet 2016; 387:2507-2520

Tapering as a Way to Quit

JAMA Feb 17, 2015: Varenicline for 24 weeks with intent to reduce daily #cigs by 50% within 4 weeks, 75% by 8 weeks, and quit attempt at week 12

By week 52, continuous abstinence = 27% for V, 10% for control.

Much greater reduction of daily cigs by weeks 4 and 8 for V group

Evidence Review* shows Stopping Smoking Increases MHCochrane Collaborative meta-analysis of 26 papers

Smoking cessation leads to: ↓depression, anxiety, stress and ↑mood and quality of life

Effect sizes of smoking cessation > or = anti-depressive drugs for mood or anxiety disorders

* Taylor et al, BMJ, 2014

Quitlines and Behavioral Health

Do quitlines work for people with MI and/or SUD?

Are they able to meet the demand?

Self-Reported Mental Health Issues Among Helpline Callers

36.9

27.8

16.1

7.1 5.2

48.9

0

10

20

30

40

50

60

Depre

ssio

n

Anxi

ety

Bip

olar

Schiz

ophrenia

Dru

g/Alc

oholAny

(Zhu,et al, 2009. Unpublished data)

% S

mo

kin

g

Conclusion and Next Steps

Smoking Profile, 2016

Most policymakers live in a non-smoking “gated community”

Smoking now marginalized to poor and disadvantaged, plus some “young immortals”

Thus tobacco control=social justice issue

New products/markets: e-cigs and marijuana

Tobacco industry fights domestic rear guard action while expanding overseas

The Electronic Cigarette*

Aerosolizes nicotine in propylene glycol soluent; e-cig products in evolution

Nicotine content in cartridge varies

Safety unproven, but >cigarette smoke

Probably deliver < nicotine than promised

Unclear if help smokers quit

Not approved by FDA

My advice: avoid unless patient insists

September 2016: Cochrane review suggests that e-cigarettes can help people quit smoking; also no noted health side effects from vapers up to 2 years

>50% of teen vapers only use flavoring, not nicotine**

* Cobb & Abrams. NEJM July 21, 2011; Fiore, Schroeder, Baker, NEJM Jan 23, 2014

Cigarette and E-Cigarette Use among High School Students, 2000-2014

Source: Youth Risk Behavior Survey

Schroeder Conclusions regarding Electronic Cigarettes Products evolving, so risk reports dated

Data on smoking cessation efficacy unclear; ? 15% or so

Much safer than combustible cigs (British MDs: 5% risk)

Riskier than room air

Second hand exposure less dangerous than regular cigs, but should not expose others in closed spaces

Flavored marketing targets youth; should ban

Nicotine exposure to adolescent brain unwise

Ideal solution=cessation, but keep away from youth

No evidence large scale gateway