Smoking Cessation in Mental Health and Primary Care Practice 13 th - - PowerPoint PPT Presentation

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, MD Distinguished Professor of Health and Health Care Department of Medicine, UCSF Director, 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 Progress

A Report of the Surgeon General

1964 2014

50 Years of Tobacco Control JAMA

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

10 20 30 40 50 60 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010

Female

Percent

Male Female

Smoking Prevalence and Average Number

• f Cigarettes Smoked per Day per Current

Smoker 1965-2010

*January-March 2015: 15.3% prevalence! Percent/Number of Cigarettes Smoked Daily

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

20 85 43 29 17 365 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 Paradox

• As 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 accumbens Ventral tegmental area

Nicotine Addiction

• Tobacco users maintain a minimum serum

nicotine 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

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

Percent quit

16.3 15.9 10.0 9.8 18.9 8.4 23.9 11.8 17.1 9.1 18.9 10.6 12.0 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 Varenicline Safety*

• 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 MH

• Cochrane 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
• r 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 10 20 30 40 50 60 Depression Anxiety Bipolar Schizophrenia Drug/Alcohol Any

(Zhu,et al, 2009. Unpublished data)

% Smoking

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
• verseas

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