Smoking Cessation in Mental Health and Primary Care Practice 13 th Annual Statewide Integrated Care Conference Integrating Substance Use, Mental Health, and Primary Care Services: Courageous and Compassionate Care Steven A. Schroeder, MD Distinguished Professor of Health and Health Care Department of Medicine, UCSF Director, Smoking Cessation Leadership Center 10/19/2016
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 Trends in cigarette current smoking among persons aged 18 or older 60 15.1% of adults are 50 Male Male current smokers 40 Percent 30 Female Female 18.8% 20 14.8% 10 0 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 68.9% want to quit 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
Smoking Prevalence and Average Number of Cigarettes Smoked per Day per Current Smoker 1965-2010 Percent/Number of Cigarettes Smoked Daily *January-March 2015: 15.3% prevalence! Source: Schroeder, JAMA 2012; 308:1586; *CDC/NCHS, National Health Interview Survey, 1997-March 2015, Sample Adult Core
Behavioral Causes of Annual Deaths in the United States, 2000 450 435 400 365 350 300 250 200 * 150 112 85 100 43 50 29 20 17 0 Sexual Alcohol Motor Guns Drug Obesity/ Smoking Behavior Vehicle Induced Inactivity * Also suffer from mental Source: Mokdad et al. JAMA 2004;291:1238-1245; Mokdad et al. JAMA. 2005; 293:293 illness and/or substance Flegal KM, Graubard BI, Williamson DF, Gail, MH. Excess deaths associated with abuse underweight, overweight, and obesity. JAMA 2005;293:1861-1867
Health Consequences of Smoking Cancers Cardiovascular diseases • Acute myeloid leukemia • Abdominal aortic aneurysm • Bladder and kidney • Coronary heart disease • Cervical • Cerebro-vascular disease • Colon, liver, pancreas • Peripheral arterial disease • Esophageal • Type 2 diabetes mellitus • Gastric Reproductive effects • Laryngeal • Reduced fertility in women • Lung • Poor pregnancy outcomes (ectopic pregnancy, • Oral cavity and pharyngeal congenital anomalies, low birth weight, preterm • Prostate ( ↓ survival) delivery) Pulmonary diseases • Infant mortality; childhood obesity • Acute (e.g., pneumonia) Other effects: cataract; osteoporosis; Crohns; • Chronic (e.g., COPD) periodontitis,; poor surgical outcomes; • Tuberculosis Alzheimers; rheumatoid arthritis; less sleep U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General, 2010.
Causal Associations with Second-hand Smoke There is no Developmental Carcinogenic safe level of – Low birthweight – Lung cancer second-hand – Sudden infant death syndrome – Nasal sinus cancer smoke. (SIDS) – Breast cancer? (younger, – Pre-term delivery premenopausal women) -- Childhood depression Respiratory Cardiovascular – Asthma induction and – Heart disease mortality exacerbation – Acute and chronic coronary heart – Eye and nasal irritation disease morbidity – Bronchitis, pneumonia, otitis – Altered vascular properties media, bruxism in children – Decreased hearing in teens USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General.
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” S ub C ulture U rban M arketing
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?
Dopamine Reward Pathway Prefrontal cortex Dopamine release Stimulation of nicotine receptors Nucleus accumbens Ventral Nicotine enters tegmental brain 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 Physiologic Behavioral The addiction to nicotine The habit of using tobacco Treatment Treatment Medications for cessation Behavior change program Treatment should address the physiologic and the behavioral aspects of dependence.
PHARMACOTHERAPY “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.” * Includes pregnant women, smokeless tobacco users, light smokers, and adolescents. Medications significantly improve success rates. Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
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.
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