Welcome to ’s 6th Annual Best Practices Conference

January 19, 2012

Sheraton Columbia Town Center Hotel Columbia, MD

Overview of the Conference

• We are delighted to have Drs. Lillian Eby and Judith Prochaska as Keynote Speakers to help us focus on smoking in addiction and mental health populations

• Updates During Lunch

– Updates on Current and Upcoming Legislation

• Kathleen Dachille & Rita Turner of the Legal Resource Center

– Updates from DHMH and the Cigar Trap Campaign

• Dr. Donald Shell and Dawn Berkowitz

– Fax to Assist Award of Recognition

– SAMHSA & SCLC’s Survey - Stephen Stahley,

• Afternoon Sessions

– Treating Tobacco in Smokers with Mental Illness, Dr. Prochaska

– Treating Tobacco is Smokers with Substance Use Disorders, Drs. DiClemente & Eby

Topic outline for this address

• A Decade of Data

– Youth Data

– Adult Data

• Interactions among smoking, alcohol and marijuana

• Why a focus on Mental Health and Substance abuse – SAMHSA and the Smoking Leadership Conference

– Partnerships with MHA and ADAA

– Ambitious Goals for Maryland

• Quitline and Mental health smokers

• Current and Upcoming Initiatives

A DECADE OF MARYLAND DATA

2000 to 2010

Data from DHMH Legislative Report (2011):

http://fha.maryland.gov/pdf/ohpetup/HG13-1004d-FHA-BiennialTobaccoReport.pdf

Figure from DHMH Legislative Report (2011):

http://fha.maryland.gov/pdf/ohpetup/HG13-1004d-FHA-BiennialTobaccoReport.pdf

Current Underage MD High School Tobacco Users:

Tobacco Products Used in 2010

Figure from DHMH Legislative Report (2011):

http://fha.maryland.gov/pdf/ohpetup/HG13-1004d-FHA-BiennialTobaccoReport.pdf

SMOKING, ALCOHOL & MARIJUANA USE AMONG UNDERAGE YOUTH

UNDERAGE SMOKERS DO NOT JUST SMOKE TOBACCO

Figure from DHMH Legislative Report (2011):

http://fha.maryland.gov/pdf/ohpetup/HG13-1004d-FHA-BiennialTobaccoReport.pdf

Current Underage MD High School Substance Users:

Use of Cigarettes, Alcohol, and/or Marijuana in 2010

SEQUENCE AND PATTERNS OF SMOKING, ALCOHOL AND MARIJUANA INITIATION IN A STATEWIDE SURVEY OF ADOLESCENTS

Society for Research on Nicotine & Tobacco Poster Presentation, March 2012

Initiation of Alcohol, Cigarettes & Marijuana

• A subsample of youth (N=4,381) who reported using all 3 substances (cigarettes, alcohol and marijuana) in the past month (5% of the 83,357 respondents)

• This subsample had more boys (56%) than girls (44%), p < .001

• Looked at age of onset and classified them into 12 different patterns of initiation based on year they reported starting each substance

• Only 4% had typical ‘gateway’ pattern: cigarettes alcohol marijuana

4 Most common Patterns of Initiation

Most Common Patterns of Initiation

Percent

Initiated Cigarettes First 12.7

Initiated Alcohol First 51.1

Initiated Marijuana First 10.1

Initiated All 3 at Same Age 26.1

Demographic Differences by Patterns of Initiation

• No demographic differences for youth who initiated cigarettes first compared to others

• Youth who initiated alcohol first

– more likely to be female and White

• Youth who initiated marijuana first

– more likely to be male, African American & older (i.e., in High School)

• Youth who initiated all 3 at same age

– more likely to be younger (i.e., in MS) and either Hispanic or from an “other’ minority group

STAGES OF INITIATION FOR SMOKING, ALCOHOL, AND MARIJUANA

TRACKING VULNERABILITY AND THE JOURNEY INTO USE

Stages of Smoking Initiation

Precontemplation: Youth who are not currently smoking and expressed a firm commitment to not start in the next year

Contemplation: Youth who are not currently smoking and did not express a firm commitment to not smoke in the next year

Preparation: Youth who have minimally tried cigarettes (< 100 in their lifetime) who may be currently smoking (less than 6 days in past 30) and definitely plan on smoking within the next year

Action: Youth who have smoked on 6 or more days during

the past 30 day and for < 6 months Maintenance: Youth who have smoked on 6+ days during

the past 30 days and for at least 6 months

DiClemente, 2003

SOSI over time by School Status PC C P A M

Middle School

2000 73.7% 20.4% 2.7% 1.9% 1.3%

2002 75.9% 19.0% 2.3% 1.6% 1.2%

2006 81.1% 15.6% 1.6% .9% .9%

2008 82.5% 14.3% 1.4% .8% 1.0%

2010 84.1% 13.3% 1.2% .8% .6%

High School

2000 51.3% 24.1% 6.3% 6.1% 12.2%

2002 57.0% 24.4% 5.3% 5.0% 8.3%

2006 64.1% 20.7% 4.7% 4.0% 6.5%

2008 66.2% 20.4% 4.1% 3.4% 5.9%

2010 67.3% 20.5% 4.0% 3.6% 4.7%

0%

20%

40%

60%

80%

100%

2000 2002 2006 2008 2010 2000 2002 2006 2008 2010

Middle School High School

Percent who would smoke cigarette if best friend offered by SOSI & school status over time

PC C P A M

0.00

1.00

2.00

3.00

4.00

2000 2002 2006 2008 2010 2000 2002 2006 2008 2010

Middle School High School

Number of 4 closest friends who smoke by SOSI and school status over time

PC C P A M

0%

20%

40%

60%

80%

2000 2002 2006 2008 2010 2000 2002 2006 2008 2010

Middle School High School

Percent who believe smoking makes young people look cool by SOSI & school status over time

PC C P A M

0%

20%

40%

60%

80%

100%

2006 2008 2010 2006 2008 2010

Middle School High School

Percent who used alcohol in the past month by SOSI & school status over time

PC C P A M

0%

20%

40%

60%

80%

100%

2006 2008 2010 2006 2008 2010

Middle School High School

Percent who binge drank (5+ drinks on one occasion) in the past month by SOSI & school status over time

PC C P A M

Stages of Substance Initiation by School Level

Substance Precontemplation Contemplation Preparation Action Maintenance

Middle School

Cigarettes 84.1 13.6 1.1 .8 0.5

Alcohol 78.7 3.9 5.8 7.4 4.3

Marijuana 84.7 4.7 3.0 4.8 2.9

High School

Cigarettes 66.9 20.6 4.2 3.6 4.7

Alcohol 32.0 21.7 13.7 17.3 15.4

Marijuana 57.1 12.9 8.0 12.4 9.6

Stages of Initiation for Cigarettes, Alcohol & Marijuana by School Level in

2010

Percentages of Stages of Smoking Initiation by Stages of Alcohol Initiation

Stages of Alcohol Initiation

Stage of Smoking Initiation Precontemplation Contemplation Preparation Action Maintenance Total

Precontemplation 73.2 14.6 7.9 4.2 0.2 73.1

Contemplation 29.1 30.7 22.4 17.2 0.6 17.8

Preparation 7.9 21.9 27.1 39.9 3.2 3.1

Action 6.1 16.6 23.2 48.6 5.5 2.7

Maintenance 4.0 14.0 15.4 52.2 14.3 3.3

Total 59.3 17.7 11.7 10.4 0.9 100

Percentages of Stages of Smoking Initiation by Stages of Marijuana Initiation

Stages of Marijuana Initiation

Stage of Smoking Initiation Precontemplation Contemplation Preparation Action Maintenance Total

Precontemplation 89.7 5.7 2.2 2.2 0.2 73.5

Contemplation 62.8 19.9 8.6 7.9 0.8 17.9

Preparation 23.4 22.7 20.7 28.7 4.5 3.0

Action 17.2 16.8 18.4 40.7 7.0 2.6

Maintenance 12.3 11.2 10.6 42.4 23.5 3.1

Total 78.6 9.2 4.6 6.3 1.4 100

Youth Substance Use: Alarming Trend of Cigar Use Prevalence

Figure from DHMH Legislative Report (2011):

http://fha.maryland.gov/pdf/ohpetup/HG13-1004d-FHA-BiennialTobaccoReport.pdf

Adult Data: Behavioral Risk Factor Surveys (BRFSS)

TRACKING THE JOURNEY OF CESSATION

Data from DHMH Legislative Report (2011):

http://fha.maryland.gov/pdf/ohpetup/HG13-1004d-FHA-BiennialTobaccoReport.pdf

Source: Behavioral Risk Factor Surveillance Surveys, 2000 - 2010

0

10

20

30

2002 2004 2006 2008 2010

% R

ep

ort

ing

Haz

ard

ou

s D

rin

kin

g

Percent of Maryland Adults Reporting Hazardous Drinking (> 2 drinks/day for Men & 1 drink / day for Women)

by Smoking Status and Year (BRFSS)

Never Smoker Former Smoker Current (Nondaily) Smoker Current (Daily) Smoker

0

10

20

30

40

50

2002 2004 2006 2008 2010

% R

ep

ort

ing

Pas

t M

on

th B

inge

Dri

nki

ng

Percent of Maryland Adults Reporting Binge Drinking (5+ for Men; 4+ for Women)

by Smoking Status and Year (BRFSS)

Never Smoker Former Smoker Current (Nondaily) Smoker Current (Daily) Smoker

BEHAVIORAL HEALTH INITIATIVES

SMOKING AMONG INDIVIDUALS WITH MENTAL HEALTH AND SUBSTANCE ABUSE PROBLEMS

Tobacco Disproportionately Affects…

• Homeless, underinsured, unemployed and mentally ill populations.

• People with mental illness…

– consume 44% of the U.S.-made cigarettes smoked each year.

– account for nearly 50% of tobacco-related deaths in the U.S. each year.

– are often not advised to quit smoking by health care providers.

National Behavioral Health Smoking Prevalence Statistics

DIAGNOSIS PERCENTAGE

Major Depression 50-60%

Anxiety Disorder 45-60%

Bipolar Disorder 55-70%

Schizophrenia 65-85%

Note: Compared to approximately 22% of people without mental health disorders

Source: http://www.nasmhpdorg/general_files/publications/NASMHPD.toolkit.final.pdf NASMHPD Tobacco-– Free Living in Psychiatric Settings. A Best Practices Toolkit Promoting Wellness and Recovery, September 2007.

Alcohol, Drug Use and Current Smoking

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

None (60 of 301) Alcohol Only

(4,614 of 7,941)

Alcohol & 1 Drug

(5,984 of 8,791)

Alcohol & 2+ Drugs (4,893 of

6,575)

1 Drug (6,652 of 10,130)

2 Drugs (5,087 of

6,289)

3+ Drugs (2,783 of

3,440)

19.9%

58.1% 68.1%

74.4%

65.7%

80.9% 80.9%

Pe

rce

nta

ge o

f Sm

oke

rs

Number of Substances (Alcohol and Drugs)

Source: 2010 ADAA

(N= 43,467 persons admitted to State-Funded Alcohol and Drug Abuse Treatment )

Poly Substance Use by Persons Admitted to Addiction Treatment in Maryland

is Related to an Increased Likelihood of Current Smoking

Maryland 4th State Chosen for SAMHSA & SCLC’s Leadership Academy, 5/31-6/1/11

• Convened leaders in Maryland to work on

– reducing smoking and nicotine addiction among behavioral health consumers and staff,

– create an environment of cooperation and collaboration among the fields of public health and mental health and substance use prevention.

– Created 4 Workgroups

1. Peer Empowerment 3. Training & Education

2. Clinical & Staff Support 4. Regulatory & Structural

2010 Smoking Rates in Maryland Addiction/Mental Health Clients

Data Sources: Addictions data are at admissions. Mental health data are throughout treatment

Best Practices for Co-Occurring Disorders

• Research has indicated that mental health and addictions treatment centers are not providing cessation services and not systematically when it is offered (Hunt et al., 2011; Thorndike, Stafford, &

Rigotti, 2001)

• Treating Tobacco Use and Dependence: 2008 Update – TTUD recommendations:

• Smoking cessation for all health care settings including SUD treatment

– All smokers should be offered treatment

• Brief interventions (identify and engage)

– Patients unwilling to quit be provided with brief intervention to build motivation

– Patients willing to quit be offered evidence based treatment

• Treatment services (treat nicotine addiction)

– Counseling

– Medications (NRT, Chantix®, Zyban®)

Use of QL with Co-occurring Populations

• Quitlines help increase success by an average of 56% over simple self help materials

• Quitlines are Accessible, Efficient, and Appealing to those less likely to seek help in traditional group settings

• The prevalence of current mental illness among Quitline (QL) callers ranges from 19%- 50% (Canadian Smokers’

Helpline, 2009 unpublished data; Hrywna et al., 2007; Kreinbring & Dale, 2007; McAfee, Tutty, Wassum, & Roberts, 2009; Tedeschi, Zhu, & Herbert, 2009).

Self-Reported Mental Health Issues Among Callers

(Zhu,et al, 2009. Unpublished data); from Webinar ”Do Quitlines Have a Role in Serving the Tobacco

Cessation Needs of Persons with Mental Illnesses and Substance Abuse Disorders?”

Efforts in Hospitals-Cessation

Friends and Family • Friends and family the top referral source to

the QL in the state of MD

• Enhance efforts to reach and engage populations by incorporating friends and family into cessation efforts when and if possible

• Particularly important with Mental Health and Substance Abuse to empower family and peer support for cessation

Current & Existing State Initiatives • Addressing Tobacco Use in Behavioral Health

populations (collaborations with MHA and ADAA and leadership initiatives)

• Promoting Hospital Cessation Best Practices

• Engaging Insurers and Employers

• Medicaid benefits for smokers

• Preparing smokers to call Quitline

• Training Healthcare Providers in SBIRT and Fax to Assist