TREATING TOBACCO DEPENDENCE in SMOKERS with COOCCURRING SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS:

1
TREATING TOBACCO DEPENDENCE in SMOKERS with
CO-OCCURRING SUBSTANCE ABUSE OR MENTAL HEALTH
DISORDERS SCIENTIFIC OVERVIEW

• Judith J. Prochaska, PhD, MPH
• University of California, San Francisco

2
RATES of TOBACCO USE

• Smoking rate among individuals with mental
  illness is 2 to 4 xs that of the general
  population (Hughes, 1993 Poirier, 2002)
• As many as 74 to 88 of individuals with
  addictive disorders smoke (Kalman, 1998),
  compared to 23 in the general population (CDC,
  2002)
• Account for 44 to 46 of cigarettes sold in the
  US (Lasser et al., 2000 Grant et al., 2004)

175 billion cigarettes 39 billion in annual sales
3
TRAJECTORIES OF USE

• Earlier initiation of smoking
• Heavier smoking
• Greater nicotine dependence
• Greater difficulty with quitting
• Greater psychiatric, cognitive, medical
  comorbidities
• (e.g., Breslau et al., 1996 Burling et al.,
  1997 Novy et al., 2001 Richter et al., 2002
  Saxon et al., 2003)

4
TRENDS in US ADULT SMOKING 19552004
Trends in cigarette smoking among persons aged 18
or older
20.9 of adults are current smokers
Male
Percent
Female
22.9
17.5
Graph provided by the Centers for Disease Control
and Prevention. 1955 Current Population Survey
19652004 NHIS. Estimates since 1992 include
some-day smoking.
5
SMOKING by DIAGNOSIS
41.0 Overall
National Comorbidity Survey 1991-1992 Source
Lasser et al., 2000 JAMA
Active
6
SMOKING in CALIFORNIA
Acton, Prochaska, Kaplan, Small Hall. (2001)
Addict Behav Prochaska, Gill, Hall. (2004)
Psychiatric Services
7
TOBACCO KILLS

• Individuals with mental illness die, on average,
  25 years prematurely (Colton Manderscheid,
  2006)
• elevated risk for respiratory and cardiovascular
  diseases and cancer, compared to age-matched
  controls (Brown et al., 2000 Bruce et al., 1994
  Dalton et al., 2002 Himelhoch et al., 2004
  Lichtermann et al., 2001 Sokal, 2004).
• Current tobacco use is predictive of future
  suicidal behavior, independent of depressive
  symptoms, prior suicidal acts, and other
  substance use (Breslau et al., 2005 Oquendo et
  al., 2004, Potkin et al., 2003).

8
TOBACCO OTHER DRUG USE

• Half of all deaths among individuals treated for
  alcohol dependence were tobacco-related (Hurt et
  al., 1996)
• Death rate 4 times greater among long-term drug
  abusers who smoke cigarettes vs. those who do not
  (Hser et al., 1994)
• Synergistic health consequences of tobacco and
  other drug use 50 greater than the sum of each
  individually (Bien Burge, 1990)

9
COMPARATIVE CAUSES of ANNUAL DEATHS in the UNITED
STATES
Individuals with mental illness or substance use
disorders
Number of Deaths (thousands)
AIDS Obesity Alcohol Motor
Homicide Drug Suicide Smoking

Vehicle Induced
Source CDC
10
HEALTH RISKS ASSOCIATED with CHRONIC TOBACCO USE

• Cardiovascular disease
• Lung Disease
• Cancers
• Delayed healing recovery after surgery
• Dyslipidemia
• Hypertension
• Macular degeneration
• Cataract
• Osteoporosis

• Periodontal disease
• Sexual dysfunction
• Reduced fertility in women
• Poor pregnancy outcomes
• SIDS, child asthma
• Mental Illness

11
COMPOUNDS in TOBACCO SMOKE
An estimated 4,800 compounds in tobacco smoke
Gases (500 isolated)
Particles (3,500 isolated)

• Carbon monoxide
• Hydrogen cyanide
• Ammonia
• Benzene
• Formaldehyde

• Nicotine
• Nitrosamines
• Lead
• Cadmium
• Polonium-210
• Arsenic

11 proven human carcinogens
12
LIGHT CIGARETTES

• The difference between Marlboro and Marlboro
  Lights

• There are no true health benefits to light
  cigarettes.
• Smokers compensate by either smoking more
  intensely (deeper inhalation) or by obstructing
  the vents.

an extra row of ventilation holes
Image courtesy of Mayo Clinic Nicotine Dependence
Center - Research Program / Dr. Richard D. Hurt
The Marlboro and Marlboro Lights logos are
registered trademarks of Philip Morris USA.
13
NO SAFE LEVEL of SMOKING

• Smoking even 1 to 4 cigarettes a day nearly
  triples the risk of death from heart disease
• Smokers who consume fewer cigarettes can reduce
  their risk of lung cancer, but still face a much
  larger risk of premature death or disability
  compared with people who quit

Source Godtfredsen et al. (2005) JAMA, Bjartveit
et al. (2005) Tobacco Control
14
QUITTING HEALTH BENEFITS
Time Since Quit Date
Circulation improves, walking becomes easier
Lung function increases up to 30
Lung cilia regain normal function Ability to
clear lungs of mucus increases Coughing, fatigue,
shortness of breath decrease
2 weeks to 3 months
1 to 9 months
Excess risk of CHD decreases to half that of a
continuing smoker
1 year
Risk of stroke is reduced to that of people who
have never smoked
5 years
Lung cancer death rate drops to half that of a
continuing smoker Risk of cancer of mouth,
throat, esophagus, bladder, kidney, pancreas
decrease
10 years
Risk of CHD is similar to that of people who have
never smoked
after 15 years
15
YEARS of SURVIVAL GAINED RELATIVE to CONTINUED
SMOKING
Source DH Taylor et al., 2002 American Journal
of Public Health
16
WHY ADDRESS TOBACCO USE in PSYCHIATRIC
POPULATIONS?
Prevent Death Improve Health Optimize Psychiatric
Medication Effects Reduce Isolation Patient
Savings
Tobacco Industry Profits Interest
groups/politicians supported by Tobacco
Industry Tax revenues
17
WHY do INDIVIDUALS with MENTAL ILLNESS SMOKE?
Smoking in adolescence is associated with
psychiatric disorders in adulthood, including
panic disorder, GAD and agoraphobia, depression
and suicidal behavior, substance use disorders,
and schizophrenia (Breslau et al., 2004 Weiser
et al., 2004 Goodman, 2000 Johnson et al., 2000)
MENTAL ILLNESS
SMOKING
Active psychiatric disorders are associated with
daily smoking and progression to nicotine
dependence (Breslau et al., 2004).
18
FACTORS ASSOCIATED with TOBACCO USE in those with
MENTAL ILLNESS
Psychological/Behavioral Conditioning effects
Coping tool Social interactions
Boredom
Biologic Pharmacologic Genetic
predisposition Alleviation of
withdrawal Pleasure effects
Weight control
Tobacco Use
Systemic Treatment Use of cigarettes for
reinforcement Tobacco industry marketing
efforts Failure to treat in psychiatry
addiction treatment settings
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NEUROCHEMICAL and RELATED EFFECTS of NICOTINE
N I C O T I N E

• Dopamine
• Norepinephrine
• Acetylcholine
• Glutamate
• ?-Endorphin
• GABA
• Serotonin

? Pleasure, reward ? Arousal, appetite
suppression ? Arousal, cognitive enhancement ?
Learning, memory enhancement ? Reduction of
anxiety and tension ? Reduction of anxiety and
tension ? Mood modulation, appetite suppr.
Benowitz. Nicotine Tobacco Research
19991(suppl)S159S163.
20
DOPAMINE REWARD PATHWAY
Prefrontal cortex
Dopamine release
Stimulation of nicotine receptors
Nucleus accumbens
Ventral tegmental area
Nicotine enters brain
Amygdala
21
CHRONIC ADMINISTRATION of NICOTINE EFFECTS on
the BRAIN
Image courtesy of George Washington University /
Dr. David C. Perry
Perry et al. J Pharmacol Exp Ther
199928915451552.
22
GENETIC EFFECTS on NICOTINE METABOLISM
4.4
0.4
9.8
Nornicotine
Nicotine-1'- N-oxide
Nicotine
Nicotine
Nicotine glucuronide

• CYP2A6
• Aldehyde oxidase

4.2
80
Trans-3'- hydroxycotinine
Trans-3'- hydroxycotinine
Cotinine
Cotinine
13.0
33.6
Trans-3'- hydroxycotinine glucuronide
Cotinine glucuronide
12.6
Norcotinine
7.4
Cotinine- N-oxide
2.0
Reprinted with permission, Benowitz et al., 1994.
2.4
23
Source S.M. Stahl (2000). Essential
Psychopharmacology
24
Source S.M. Stahl (2000). Essential
Psychopharmacology
25
NICOTINE ADDICTION CYCLE
Reprinted with permission. Benowitz. Med Clin N
Am 19922415437.
26
NICOTINE WITHDRAWAL EFFECTS

• Dysphoric or depressed mood
• Insomnia and fatigue
• Irritability/frustration/anger
• Anxiety or nervousness
• Difficulty concentrating
• Impaired task performance
• Increased appetite/weight gain
• Restlessness and impatience
• Cravings

Most symptoms peak 2448 hr after quitting and
subside within 24 weeks.
American Psychiatric Association. (1994). DSM-IV.
Hughes et al. (1991). Arch Gen Psychiatry
485259. Hughes Hatsukami. (1998). Tob Control
79293.
Not considered a withdrawal symptom by DSM-IV
criteria.
27
WHAT is ADDICTION?

• Compulsive drug use, without medical purpose, in
  the face of negative consequences
• Alan I. Leshner, Ph.D.
• Former Director, National Institute on Drug Abuse
• National Institutes of Health

28
SYSTEMIC and TREATMENT FACTORS
29
PSYCHIATRISTS in PRACTICE (Himelhoch Daumit,
2003)

• 1992-96 Natl Ambulatory Medical Care Survey
• 23 of psychiatric visits dropped from analysis
  because patient smoking status unknown
• For patients identified as smokers (N1610)
• Cessation counseling offered at 12 of visits
• Nicotine Dependence not diagnosed at any visit
• NRT never prescribed

30
PSYCHIATRY RESIDENTS (N105) ENGAGEMENT in the
5-As
Nationally, only 50 of Adult Psychiatry
Residency Programs provide training in treating
nicotine dependence. Training duration is a
median of 1-hour (Prochaska et al., 2006).
Source Prochaska, Fromont et al., 2005 Acad
Psychiatry
31
ATTENTION to TOBACCO USE in ADDICTION TREATMENT

• Absent from most addictions treatment settings
• 223 addiction treatment programs in Canada
• 10 offered formal smoking cessation programs
• 54 reported placing very little emphasis on
  smoking
• 47 still allowed smoking indoors (Currie et al.,
  2003).
• Reluctance to encourage smoking cessation for
  fear that sobriety may be compromised

32
BARRIERS to TREATING TOBACCO

• Smoking not viewed as a clinical issue
• Our clients arent interested in quitting
• Our clients cant quit
• Our clients need to smoke to manage their
  psychiatric symptoms and/or sobriety
• Lack of training among providers
• Not enough time, money

33
BARRIERS to TREATING TOBACCO

• Smoking not viewed as a clinical issue
• Our clients arent interested in quitting
• Our clients cant quit
• Our clients need to smoke to manage their
  psychiatric symptoms and/or sobriety
• Lack of training among providers
• Not enough time, money

34
SMOKING in PSYCHIATRY
35
Tobacco Documents
Department of Health, Education, and
Welfare National Institute of Mental
Health Washington, DC August 4, 1980
I am writing to request a donation of cigarettes
for long-term psychiatric patientsbecause of
recent changes in the DHHS regulations, Saint
Elizabeth Hospital can no longer purchase
cigarettes for them.
I am therefore requesting a donation of
approximately 5,000 cigarettes a week (8 per day
for each of the 100 patients without funds).
36
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JCAHO DECISION
JCAHO ultimately yielded to massive pressure
from mental patients and their families, relaxing
a policy that called on hospitals to ban
smoking.
An exception was made to allow continued smoking
in psychiatric inpatient and substance use
facilities for long-term patients.
38
LD 463 - An Act to Exempt Substance Abuse and
Psychiatric Patients from the Prohibition against
Smoking in Hospitals
39
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DSM-IV TOBACCO USE DISORDERS

• Nicotine Withdrawal
• Daily use of nicotine
• Abrupt cessation/reduction followed within 24 hrs
  by 4
• Depressed mood
• Insomnia
• Irritability
• Anxiety
• Difficulty concentrating
• Decreased HR
• Increased appetite
• Clinically significant impairment
• Not due to GMC

• Nicotine Dependence
• Maladaptive pattern of use with significant
  impairment manifested by 3 in 12-months
• Tolerance
• Withdrawal
• ? Use
• Unsuccessful efforts to stop
• Time investment
• Loss of important activities
• Continued use despite knowledge of physical or
  psychological problems

The majority of smokers with mental illness meet
criteria for DSM-IV nicotine dependence and
withdrawal (Prochaska et al., 2004 2006)
41
TOBACCO IMPACTS TREATMENT
Significant group difference in rates of
against medical advice (AMA) hospital discharge
(?2 6.79, df 2, p .034), even after
controlling for group differences.
Prochaska, Gill, Hall. (2004) Psychiatric
Services
42
PHARMACOKINETIC DRUG INTERACTIONS of SMOKING
Drugs that may have a decreased effect due to
induction of CYP1A2

• Caffeine
• Clozapine (Clozaril)
• Fluvoxamine (Luvox)
• Haloperidol (Haldol)
• Olanzapine (Zyprexa)
• Phenothiazines (Thorazine, Trilafon, Prolixin,
  etc.)

• Propanolol
• Tertiary TCAs / cyclobenzaprine (Flexaril)
• Thiothixene (Navane)
• Other medications estradiol, mexiletene,
  naproxen, phenacetin, riluzole, ropinirole,
  tacrine, theophyline, verapamil, r-warfarin (less
  active), zolmitriptan

(Zevin Benowitz, 1999)
Smoking cessation may reverse the effect.
43
WHY MENTAL HEALTH and ADDICTION TREATMENT
PROVIDERS?

• Often the clinician for whom contact is the most
  frequent and who knows the patient best
• Able to combine psychopharmacological and
  behavioral/counseling treatment
• Trained in substance abuse treatment
• Able to identify and address any changes in
  mental health or other substance use during the
  quit attempt

44
BARRIERS to TREATING TOBACCO

• Smoking not viewed as a clinical issue
• Our clients arent interested in quitting
• Our clients cant quit
• Our clients need to smoke to manage their
  psychiatric symptoms and/or sobriety
• Lack of training among providers
• Not enough time, money

45
STUDIES of PSYCHIATRIC PATIENTS READINESS to
QUIT
Smokers with mental illness are just as ready to
quit smoking as the general population of smokers.

• No relationship between psychiatric symptom
  severity and readiness to quit

46
INTEREST in TREATMENT

• Stage-based tobacco treatment study in inpatient
  psychiatry recruiting 82 of eligible smokers
  (Prochaska et al., in process)
• Stage-based tobacco treatment study with
  depressed smokers 32 entered Cessation
  Treatment component (Haug et al., 2005)

47
TIMING of TOBACCO TREATMENT

• 44 - 80 of individuals in addictions treatment
  report interest in quitting their tobacco use
• 17 - 41 report concern that quitting during
  addictions treatment may make it harder to stay
  sober (Asher et al., 2003 Irving et al., 1994
  Stein Anderson, 2003)
• Questions of when and how best to intervene

48
BARRIERS to TREATING TOBACCO

• Smoking not viewed as a clinical issue
• Our clients arent interested in quitting
• Our clients cant quit
• Our clients need to smoke to manage their
  psychiatric symptoms and/or sobriety
• Lack of training among providers
• Not enough time, money

49
TREATMENT of DEPRESSED PSYCHIATRIC OUTPATIENTS
for CIGARETTE SMOKING

• Sharon Hall, PhD, Janice Tsoh, PhD, Judith
  Prochaska, PhD, MPH, Stuart Eisendrath, MD,
  Joseph Rossi, PhD, Colleen Redding, PhD,
• Amy Rosen, PsyD, Marc Meisner, MD, Gary Humfleet,
  PhD, Julie Gorecki, MA
• University of California, San Francisco
• Supported by NIDA P50 DA09253
• Am J Public Health 2006

50
STUDY DESIGN

• 322 depressed smokers recruited from four
  outpatient psychiatry clinics
• Stepped Care Intervention
• Stage-based expert system counseling
• Nicotine patch
• 6 session individual CBT counseling
• Bupropion available
• Brief Contact Control
• Primary outcome
• 7 day PPA _at_ 12 18 months, CO verified

51
ABSTINENCE RATES by TREATMENT CONDITION


p 52
MENTAL HEALTH OUTCOMES

• Among depressed smokers who quit
• No increase in suicidality
• Quit 0 vs Smoking 1-4
• No increase in psych hospitalization
• Quit 0-1 vs. Smoking 2-3
• Comparable improvements in BDI and STAXI scores
  and of days with emotional problems

Prochaska et al., in press, Am J Public Health
53
BDI TOTAL SCORE
Moderate
Mild
Minimal
54
TREATING DEPRESSED SMOKERS

• Stage-based tobacco treatment with CBT and NRT
  significant effects at 12 and 18 months
• No evidence of worsened psychiatric symptoms
  associated with quitting smoking
• Smoking can be treated concurrent with depression
  without adverse effects to mental health
  functioning

55
A META-ANALYSIS of SMOKING CESSATION
INTERVENTIONS with INDIVIDUALS in SUBSTANCE ABUSE
TREATMENT or RECOVERY

• Judith Prochaska, PhD, MPH
• Kevin Delucchi, PhD Sharon Hall, PhD
• University of California, San Francisco
• Supported by TRDRP 11FT-0013 and NIDA P50
  DA09253
• JCCP 2004
• Journal of Consulting and Clinical Psychology,
  2004

56
STUDY PURPOSE

• To assess, in a meta-analysis, the effectiveness
  of smoking cessation interventions evaluated with
  individuals in substance abuse treatment or
  recovery
• To compare outcomes for those in treatment versus
  recovery to provide some guidance on the optimal
  timing of smoking cessation interventions in
  relation to addictions treatment

57
METHOD

• Computer-based and manual search of the research
  literature (1966-2003)
• MEDLINE, PsychINFO, EMBASE, ECO, Biosis, Cochrane
  Library, Digital Dissertations, Conference
  Abstracts (SRNT)
• Study inclusion criteria
• Randomized controlled design
• Evaluation of a smoking cessation intervention
• Subjects in addictions treatment or recovery
• Adult aged sample ( 18 years old)
• Quantitative assessment of smoking cessation
  (e.g., point prevalence abstinence)

58
SEARCH RESULTS
MEDLINE 53 citations 18 studies met
criteria 13 unique publications PsychINFO /
Biosis 0 ECO 1 additional Digital
Dissertations 1 additional Conference
abstracts 1 additional Manual biblio search 3
additional Total 19 studies (1991-2003) In
Treatment 12 studies (N1410) In
Recovery 7 studies (N638)
59
DATA EXTRACTION

• Studies independently reviewed by two reviewers
• One blinded to authors, institution, journal,
  title, pub year, refs
• Abstinence rates at post-treatment and longest
  follow up (i.e., 6- to 12-months) abstracted
• Most conservative estimates used (i.e., biochem
  verified, ITT)
• PPA, reported in 15 studies, used as smoking
  outcome
• For drug/alcohol outcomes, any use counted as
  relapse to be conservative and for consistency
  across studies
• Lead authors contacted to provide additional
  information when necessary

60
DESCRIPTION of STUDIES

• Sample sizes 22 575 (Mdn 63)
• Settings
• 7 residential (e.g., VA residential, psychiatric
  dual diagnosis, perinatal drug abuse tx program)
• 12 outpatient (e.g., methadone clinics, primary
  care, university)

All comparisons p
61
INTERVENTIONS

• Pharmacological
• NRT 11
• Bupropion 1
• Fluoxetine 1
• Methadone ? 1

• Psychosocial
• Brief advice/educational 4
• Skill training/behavioral 6
• CBT 4
• Stage-based/motivational 4
• Nicotine anonymous 1
• Generalization to sobriety 6

Number of contacts 1 36 M 12 Session
contact length 5 min 2 hrs M 42
min Intervention duration 1 day 1 yr M
13 wks Total contact 15 min 24 hrs M
8.3 hrs
62
ANALYSES

• Abstinence status by condition recorded in 2x2
  tables using Comprehensive Meta-Analysis
  (Biostat, Englewood, NJ)
• Abstinence rates expressed as relative risks
  (RRs) with 95 confidence intervals (CIs)
  (Fleiss, 1993)
• RR 1.00 favors intervention for increased
  abstinence relative to control
• Effects calculated for smoking and substance use
  at post-tx and longest FU (6- to 12-mos).
  Multiple intervention groups collapsed and
  compared to control group.
• Random-effects models, incorporating variance
  between study findings in a weighted average of
  rate ratios, used to estimate overall RR and 95
  CI (DerSimonian Laird, 1986).
• Heterogeneity of pooled results, p considered significant (Oxman et al., 1994).

63
Post-Treatment Smoking Outcomes
64
Subgroup Analyses Post-Treatment Smoking
Cessation Effects for In-Treatment Studies
65
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66
OVERALL SMOKING CESSATION RATES
PostTreatment Long-term FU
18 studies
15 studies
67
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68
DRUG ALCOHOL ABSTINENCE RATES among
PARTICIPANTS IN TREATMENT
9 studies
7 studies
69
CONCLUSIONS

• Significant treatment effects for quitting
  smoking at post-treatment, but not at long-term
  follow up ( 6 months)
• At long-term follow up, evidence of improved
  sobriety among intervention participants
• 25 greater odds of being sober if exposed to the
  tobacco cessation intervention

70
CONCLUSIONS

• Contrary to previous concerns, smoking cessation
  efforts delivered during addictions treatment
  appeared to enhance, rather than compromise,
  long-term sobriety
• Potential mechanisms may relate to
• extended intervention contact time
• reduced cues to substance use
• practice with relapse prevention skills
• increased sense of mastery
• positive overall change in lifestyle

71
BARRIERS to TREATING TOBACCO

• Smoking not viewed as a clinical issue
• Our clients arent interested in quitting
• Our clients cant quit
• Our clients need to smoke to manage their
  psychiatric symptoms and/or sobriety
• Lack of training among providers
• Not enough time, money

72
PSYCHIATRY RESIDENTS (N105) TRAINING in TOBACCO
TREATMENTS
Prochaska et al., 2005 Acad Psychiatry
73
INTEREST in FURTHER TRAINING
Prochaska et al., 2005 Acad Psychiatry
74
NATIONAL SURVEY of PSYCHIATRY RESIDENCY TRAINING
DIRECTORS

• 114 respondents (63 response rate)
• 50 of programs provide tobacco training
• Median of 1 hr duration
• Lack of faculty expertise a barrier to providing
  training
• 89 interested in evaluating a model tobacco
  cessation training curriculum
• Would dedicate 4 hrs to the training

Prochaska et al., 2006 Acad Psychiatry
75
DEVELOPMENT and EVALUATION of a TOBACCO TREATMENT
CURRICULUM for PSYCHIATRY RESIDENCY TRAINING
PROGRAMS

• 4-hr evidence-based tobacco treatment curriculum
• 3 adult psychiatry residency training programs in
  Northern California
• 56 residents (75 participation)
• Measures of knowledge, attitudes, confidence, and
  behaviors at baseline, post-training, and 3 mo
  follow up
• 6-mo chart review at one of the sites (N1204
  charts)

Prochaska et al., in press Acad Psychiatry Funded
by California TRDPR (13KT-0152)
76
RESULTS Knowledge

• Gains in knowledge scores significant from pre-
  to post-training, averaging 17 percentage
  points,
• t51 7.32, p
• Significantly associated with attendance

Fig 1. Knowledge Gains (Pre- to Post-Training),
by Attendance
77
RESULTS Attitudes
Change in Residents Perceived Barriers to
Treating Tobacco Dependence in Psychiatry
High
Barriers Scale, 10-items Cronbach
alpha0.83 Pre-training vs. post-training
t51 5.36, p t35 4.56, p

Low
78
RESULTS Attitudes
Ratings made on a 5-point scale 1strongly
disagree to 5strongly agree. p sample t-test for time comparison, where T1
pre-test, T2 post-training, and T3 3 month
follow-up
79
RESULTS Confidence
Confidence Scale, 6-items Cronbach
alpha0.82 Pre-training vs. post-training
t51 10.58, pFU t35 8.60, pExtremely confident


Not at all confident
80
RESULTS Confidence
All pre-post comparisons significant at p 81
RESULTS Self-reported Behaviors
pre-training to 3-month follow up comparison
significant at p 82
RESULTS Charted Behaviors Baseline to 3 month
follow-up (N1204 medical records)
p 83
BARRIERS to TREATING TOBACCO

• Smoking not viewed as a clinical issue
• Our clients arent interested in quitting
• Our clients cant quit
• Our clients need to smoke to manage their
  psychiatric symptoms and/or sobriety
• Lack of training among providers
• Not enough time, money

84
MEDICARE / MEDI-CAL

• Medicare covers cessation counseling and
  pharmacotherapy (NRT, bupropion) for smokers with
  tobacco-related health conditions or drug
  interactions
• Medi-Cal covers pharmacotherapy for smokers in a
  cessation program (includes toll-free quitlines)

85
COMPARATIVE DAILY COSTS of PHARMACOTHERAPY
6.07
5.88
3.75 generic
5.00 in CA
4.00
3.67
3.48 (generic)
2.84 (generic)
2.62 (generic)
1.13 (generic)
.91 (generic)
Cost per day, in U.S. dollars
86
FINANCIAL IMPACT of SMOKING
Buying cigarettes every day for 50 years _at_
3.75/pack for generic or 5.25/pack for brand
name. Money banked monthly, earning 5.5 interest
2
Packs per day
1.5
1
87
ANNUAL SMOKING-ATTRIBUTABLE ECONOMIC COSTSU.S.,
19952001
Prescription drugs, 6.4 billion
Other care, 5.4 billion
Medical expenditures (1998)
Ambulatory care, 27.2 billion
Nursing home, 19.4 billion
Hospital care, 17.1 billion
Societal costs 7.65 per pack
Annual lost productivity costs (19972001)
Men, 61.9 billion
Women, 30.5 billion
Billions of dollars
CDC. MMWR 200251300303 and MMWR
200554625-628.
88
BARRIERS to TREATING TOBACCO

• Smoking IS a clinical issue relevant to mental
  health and substance abuse treatment
• Our clients ARE interested in quitting
• Our clients CAN quit WITHOUT threat to their
  mental health recovery or sobriety
• Providers ARE INTERESTED in training and training
  programs IMPACT clinical practice
• Tobacco treatment is COST-EFFECTIVE and can be
  done efficiently

89

• Those who deliver mental health care often pride
  themselves on treating the whole patient, on
  seeing the big picture, and on not being bound by
  financial irrationality or by the biases of their
  culture yet many fail to treat nicotine
  dependence. They forget that when their patient
  dies of a smoking-related disease, their patient
  has died of a psychiatric illness they failed to
  treat.
• - John Hughes, 1997

90
ACKNOWLEDGEMENTS

• Sharon Hall, PhD, Sebastien Fromont, MD, Karen
  Hudmon, DrPH, RPh, Desiree Leek, BS
• National Institute on Drug Abuse (K23
  DA018691, P50 DA09253)
• California Tobacco Related Disease Research
  Program (13KT-0152)
• American Cancer Society (IRG AC-08-04)

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