tobacco cessation and mental health - arizona state … · tobacco cessation and mental health...
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Tobacco Cessation
and
Mental Health
Courtney Ward Arizona Department of Health Services
Bureau of Tobacco & Chronic Disease
Arizonans with Mental Illness
• Life expectancy lowers by 30 years, with
tobacco-related disease the biggest killer
• 75% of people with mental illness (approx.
100,000) use tobacco (5 x the Arizona rate)
• 33% of behavioral health providers use tobacco
(more than twice the Arizona rate)
• SAMSHA reports that over 50% of tobacco is
purchased by people with a mental illness
Facts
• Tobacco is the leading cause of death for patients previously treated for alcohol and other non-nicotine drugs of abuse
• Smoking exacerbates mental illness symptoms, HIV/AIDS symptoms, hepatitis C and other conditions
• Impact of exposure to secondhand smoke among nonsmoking clients and staff as well as family members (including children) is a very serious issue
Facts Cont’d
• The real bottom line is that with evidence
pouring in on the harm caused by
secondhand smoke, facilities are being
mandated to go smoke free; there will be
no choice
Patients Want to Quit
• Documented interest in quitting among clients
across all treatment modalities
• Standard treatment approaches work with these
patients (NRT plus behavioral counseling)
• Patients are already in a secure, supportive
environment ideal for nicotine cessation
Barriers to Success • Staff smoke in large numbers
• Tobacco use is not viewed as substance abuse
• Staff and clients smoking together is seen as informal counseling opportunity rather than a boundary or therapeutic issue
• Smoking viewed as a privilege and reward; programming is built around smoking breaks
• Tobacco is not seen as part of the treatment regimen
• Fear of behavioral management issues – nicotine withdrawal and blood levels
• Fear of medication toxicity – interaction of medications
What Are the Facts About
Smoking and Comorbidities?
Background
• 44% of cigarettes smoked in the U.S. are
consumed by individuals with a psychiatric or
substance abuse disorder
• Persons with mental illness are more than twice
as likely to smoke as others
• Roughly 60-95% of patients in addiction
treatment are tobacco dependent
• Of those individuals, roughly half smoke more
than 25 cigarettes per day
Background Cont’d • Cigarette smoking consistently appears highest
among people with psychotic disorders, but remains high also for depression, anxiety, substance abuse, and personality disorders
• An estimated 200,000 smokers with mental illness or addiction die each year due to smoking, a figure highly disproportionate to the number of those with mental disorders in the general population
Smoking and Depression
• Rates of smoking are estimated at 50-60%
in patients with a clinical diagnosis of
depression
• 25-40% of psychiatric patients seeking
smoking cessation treatment have a past
history of major depression or minor
dysthymic disorder
Smoking and Schizophrenia
• Patients with schizophrenia smoke three
times the rate of the general population
• Some studies show prevalence rates as
high as 90%
Smoking and Schizophrenia Cont’d
• Smokers with schizophrenia experience increased psychiatric symptoms, number of hospitalizations, and need for higher medication doses.
• The metabolism of tobacco (not nicotine) can dramatically affect psychiatric medication dosing requirements and blood levels by affecting the P450 liver cytochrome enzymes.
• Often smoking requires a doubling of medication dosage.
Anxiety Disorders and Tobacco • The presence of an anxiety disorder with or
without concurrent depression is associated with
an increased likelihood of smoking
• Smoking has been found to be a risk factor for
the onset of panic disorder; elevated smoking
rates are observed in patients with chronic panic
disorder
• Despite patients’ subjective reports that smoking
reduces anxiety, chronic nicotine use in animals
is related to increased anxiety
Smoking and Alcohol Dependence
• Smokers have a 2-3 times greater risk for
alcohol dependence than nonsmokers
• An estimated 80% of alcoholics currently
smoke
• More alcoholics die from smoking-related
diseases than from alcohol- related ones
• Both founders of Alcoholics Anonymous
died from their tobacco addictions
Smoking and Other Substance
Abuse
• Smoking rates are 2-3 times higher among
drug addicts than the general population
• Surveys have reported 85-98% smoking
prevalence rates in methadone
maintenance program patients
A Targeted Population
• As smoking prevalence declines, a greater
proportion of smokers are in this
population
• Tobacco companies actively target the
mentally ill and substance abusers
• This is proven through tobacco papers
(Project SCUM)
Secondhand Smoke
• Secondhand smoke contains 4000
chemicals, 50 of which are known
carcinogens, and 6 that negatively impact
childhood development and reduce fertility
in both sexes
• More non-smokers will die from exposure
to secondhand smoke than from any other
air pollutant
Secondhand Smoke Cont’d • Children of parents who smoke are at a higher
risk for developing chronic coughing, wheezing, and sputum production; middle ear infections; and asthma
• Infants are three times as likely to die from SIDS if their mothers smoked during and after pregnancy, and twice as likely if their mothers stop smoking during pregnancy but resume again following birth
What Can Be Done?
• Current situation is unacceptable
• Cessation will reduce, not increase,
suffering
• Secondhand smoke rules will force
change
• Starting now to help staff and patients quit
is vital
A Chance to Make a Real
Difference
• Highest prevalence and toughest issues in
this population
• Most to gain by breakthroughs
• Move toward mandates makes the issue
unavoidable
• If done right, this could be a tremendous
success story
What’s next?
Courtney Ward
Arizona Department of Health Services
Bureau of Tobacco & Chronic Disease
(602) 542-2075
Integrating Tobacco Free Living
into Behavioral Health Wellness
Tips and Tools for Development and Implementation
Peer-to-Peer Tobacco Recovery Program
This is a Critical Issue
What is killing the
majority of us is not
infectious disease,
but our chronic and
modifiable behaviors.
Programs Currently Implemented
Peer Support Whole Health
Appalachian Consulting Group, Inc.
Chronic Disease Self-Management Program
Arizona Living Well Institute
AshLine Partnership
ADHS/ Bureau of Tobacco and Chronic Disease
Peer-to-Peer Tobacco Recovery Program
Tobacco Dependence has
Two Parts
It is estimated that one person dies
from a tobacco-related illness
every 6 seconds
Understanding Tobacco Addiction
• Tobacco addiction is a chronic brain disease
• We need to treat the physical addiction, as well as the behavior
• The “Clinical Practice Guideline” - best strategy is a combination of
counseling and FDA approved cessation medications
• Addiction can be treated by using medications
• The behavior (habit) can be treated through programs focusing on
changing behavior such as peer support groups, counseling and
working on new behaviors
Burden of Tobacco
• 443,000 tobacco-related deaths in the U.S.
each year
• 6 million tobacco-related deaths worldwide
each year
• 8.6 million people living with tobacco-related
chronic illness
• 50,000 deaths each year in the U.S. due to
second-hand smoke exposure
It is estimated that one person dies
from a tobacco-related illness
every 6 seconds
Chemicals in Tobacco Products
Quitting Smoking Leads to a Longer and Healthier Life
It is estimated that one person dies
from a tobacco-related illness
every 6 seconds
Tobacco Cessation Strategies
Peer Groups and Quitlines
• Peer Support Whole Health
• Began in February on 2010
• Clinic Level, Peer Driven
• Chronic Disease Self-Management
• Trained Facilitators include PNO staff as well as Magellan Staff
• Behavioral Health lead Train the Trainer staff available in August
• 6 week program - groups have been well attended
Tobacco Cessation Strategies
Peer Groups and Quitlines
• Peer to Peer Tobacco Recovery Program
• 47 trained facilitators
• Weekly group with drop-in function
• Participants can join anytime
• AshLine
• Telephone counseling
• Web-based services
• Referrals for additional support
• May provide NRT or other medications
• May be available in multiple languages
Motivational Interviewing
• An intervention used to motivate people towards behavior change
• Originally a tool for recovery from addictions
• Now used in many different settings to help people change
unwanted behaviors
• The focus of this Motivational Intervention is to build the peer’s
motivation to change rather than to focus on the actual behavior
change
• Focus: Healthy Choices / Healthy Behaviors
It is estimated that one person dies
from a tobacco-related illness
every 6 seconds
Benefits of Quitting
A Wellness Philosophy
Leading a meaningful and fulfilling life through conscious and self-
directed behaviors, focused upon living at one’s fullest potential.
Quitting Tobacco and Mental Health
Courtney Ward, MPA
AZDHS BTCD
Tobacco Program Manager
What is ASHLine?
• Free help to quit tobacco – Coaching over the phone
– Self-paced quit program online
– Medication assistance
• Partner to healthcare systems and professionals – Referral program
– Technical assistance and training resources
What is ASHLine?
• Funding from the state tobacco tax through ADHS BTCD
• Housed at University of Arizona Mel and Enid Zuckerman College of Public Health
• Providing quitline services since 1995
Client services
Quit Coaches
• Client-directed, Outcome-informed approach (CDOI)
• Motivational Interviewing
• Medication assistance
Referral Outreach Team
• Contacts in Northern, Southern and Central Arizona
Client-directed, Outcome-informed
• Values the client-coach relationship
• Client determines focus, length, frequency of phone calls
– No script or curriculum
• Coaching can last anywhere from 3 to 6 months after the client quits
• The client can continue to work with the coach, even if they relapse
Motivational Interviewing
• Resolve ambivalence toward quitting
• Help develop problem solving skills
– Create a quit plan
– Withstand cravings
• Work to develop social support network to maintain tobacco free lifestyle
Medication assistance
• Two weeks of nicotine patch, gum, or lozenge available to all enrolled ASHLine clients
– Mailed directly to residence
• EXCEPT – Title XIX AHCCCS beneficiaries who can receive 12 weeks of any FDA-approved quit tobacco medication on prescription from their primary care provider
The role you play in quitting tobacco
• Tobacco use is cited as the chief avoidable cause of death in the US
• Smokers cite physician advice to quit as an important motivator
• Healthcare systems should craft policy that makes tobacco use treatment an integral part of healthcare
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.
Passive Referral vs. Proactive Referral
QuitFax referral form
Passive Referral vs. Proactive Referral
Passive Referral vs. Proactive Referral
Online Status Report
Online Follow-Up Report
WebQuit online referral
Electronic Health Records
ASHLine referral reports
• Confirmation
– Within 24 hours
• Status report
– Within 10 days
– First call within 24 hours
– Up to 5 attempts to contact over 10 days
• Monthly newsletter
Can be received by fax, email, or both!
ASHLine referral program
Three ways to refer
• QuitFax referral form
• WebQuit online referral
• Electronic Health Records
How To Implement
• Ask every client about their tobacco use at every visit: “How much tobacco have you used since our last visit?”
• Advise that “quitting smoking” is the very best thing you can do for your health”
• Refer to the Arizona Smokers’ Helpline by using the QuitFax referral program
Online
Material
Requests
Contact Information
Courtney Ward, MPA
602-542-2075
Karen Akin, MPA
800-556-6222 ext.543