Smoking and Substance Misuse

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Smoking and Substance Misuse

• Slides by Ann McNeill, Luke Mitcheson and Gay
  Sutherland
• Institute of Psychiatry, KCL

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Summary

• Relationship between smoking and substance misuse
  and treatment
• Local audits
• NICE guidance
• Next steps?

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• 3 million smokers in UK with a mental health
  disorder
• No change in prevalence in last 20-30 yrs
• Moral imperative
• Radical changes needed

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Smoking Prevalence ()
Note General Population includes all categories
of mental illness
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Healthcare Staff Culture!

• Psychiatrists have higher smoking rates than
  other medics and are less likely to treat
  nicotine addiction!
• Believe MI smokers do not want to quit
• Believe they can not quit
• Believe quitting would negatively affect their
  mental state

Wrong!
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Smoking and substance misuse

• Largest cause of preventable death, disease
  health inequalities in the UK
• High smoking prevalence previously demonstrated
  in substance misusers and interrelationship e.g.
• Smokers subjective symptoms of methadone
  inadequacy
• Smoking impedes cognitive recovery after alcohol
  abstinence
• Smokers require higher doses of some
  benozodiapines/opiates
• Tobacco/cannabis users made fewer attempts to
  quit and less likely to successfully quit than
  tobacco-only smokers

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Mortality and morbidity

• Smoking may be responsible for much of the
  increased mortality of substance misusers
  compared with general pop. Eg.
• Cohort study of 845 substance misusers in
  Minnesota
• 222 died during study
• 214 with death certificates 51
  tobacco-related death, gt than proportion from
  alcohol other drug-related causes (Hurt et al,
  1996)
• Tobacco alcohol use multiplies risk of
  developing cancers of upper respiratory
  digestive tracts (Kalman et al, 2010 Baca
  Yahne, 2009)

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NICE recommendations include

• Identifying people who smoke and offering and
  arranging support
• Implementing a comprehensive smoke-free policy
  including the grounds
• Support for staff who smoke
• Training for staff

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Treatment

• Smoking cessation does NOT impact negatively on
  success of abstinence from other substances may
  improve outcomes continued nicotine dependence
  may be a risk factor for relapse
• Meta-analysis of 19 RCTs of smoking-cessation
  interventions for people in substance misuse
  treatment and in recovery showed concurrent
  treatment of smoking resulted in a 25 increased
  likelihood of long-term abstinence from alcohol
  and illicit drugs
• Khara Okoli, 2011 Burling et al, 2001 Kalman
  et al, 2010 Baca Yahne 2009 Williams
  Ziedonis, 2004 Prochaska et al, 2004 Stapleton
  et al, 2009 Goulay et al, 1994 Moore Budney,
  2001 Prochaska et al, 2004

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Treatment

• Smoking cessation programmes exclusively
  addressing tobacco less effective for cannabis
  users

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SLaM audits

• Audit of all computerised client records across
  SLaM since 2008 for smoking status recording,
  prevalence and offer of support
• Audit of addiction wards and community services
  in SlaM in 2012-3

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Diagnosis N Smoking Status Recorded Smokers 20-22 General Pop. Received advice to quit Received referral to smoking service
Depression F32/33 26,828 12 (3,221) 34 (1,103) 72 (796) 13 (141)
Personality Disorders F60/61 4,621 22 (1,023) 64 (659) 76 (501) 17 (115)
Serious Mental Illness F20/25/31 15,954 33 (5,359) 54 (2,909) 83 (2,439) 22 (656)
Opiate use 6,491 26 (1,700) 89 (1,524) 71 (1,088) 7.4 (113)
Alcohol use 11,158 15 (1,730) 77 (1,335) 67 (906) 7.4 (129)
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Diagnosis N Smoking Status Recorded Smokers 20-22 General Pop. Received advice to quit Received referral to smoking service
Depression F32/33 26,828 12 (3,221) 34 (1,103) 72 (796) 13 (141)
Personality Disorders F60/61 4,621 22 (1,023) 64 (659) 76 (501) 17 (115)
Serious Mental Illness F20/25/31 15,954 33 (5,359) 54 (2,909) 83 (2,439) 22 (656)
Opiate use 6,491 26 (1,700) 89 (1,524) 71 (1,088) 7.4 (113)
Alcohol use 11,158 15 (1,730) 77 (1,335) 67 (906) 7.4 (129)
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Diagnosis N Smoking Status Recorded Smokers 20-22 General Pop. Received advice to quit Received referral to smoking service
Depression F32/33 26,828 12 (3,221) 34 (1,103) 72 (796) 13 (141)
Personality Disorders F60/61 4,621 22 (1,023) 64 (659) 76 (501) 17 (115)
Serious Mental Illness F20/25/31 15,954 33 (5,359) 54 (2,909) 83 (2,439) 22 (656)
Opiate use 6,491 26 (1,700) 89 (1,524) 71 (1,088) 7.4 (113)
Alcohol use 11,158 15 (1,730) 77 (1,335) 67 (906) 7.4 (129)
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SLaM audits

• Audit of all computerised client records across
  SLaM since 2008 for smoking status recording,
  prevalence and offer of support
• Audit of addiction wards and community services
  in SlaM in 2012-3

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Smoking Audit Method

• Questionnaire survey conducted across Addiction
  services in or connected to SLaM
• (Blackfriars, Lantern Hall, Beresford Project,
  Lorraine Hewitt House, AAU, Clouds House, and Ley
  Community)
• Staff and client questionnaires to measure
• smoking behaviour
• motivation to quit
• treatment provision
• attitudes towards nicotine dependence treatment
• 97 (n145) and 85 (n163) response rates for
  staff and clients respectively.

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Key Findings 1. High smoking prevalence
  Staff Clients
Ever smoked 70 (n 102) 94 (n 154)
Currently smoking 45 (n 65) 88 (n 144)
General Pop. 20
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(2) Motivated client group

• 81 of clients who smoked wanted to give up
• 23 wanted to in next 3 months
• 46 wanted to talk to someone about reducing
  harmfulness of their smoking 21 did not know
• 53 wanted advice on stopping abruptly
• 77 wanted advice on gradually reducing no. of
  cigs smoked
• 87 wanted info on NRT
• gt2/3rd of clients did not know enough about
  varenicline (Champix) or bupropion (Zyban) to
  express any interest

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3. A Lack of Treatment Provision

• Only 15 clients who smoked had been offered
  support during current treatment episode
• 56 had never been offered support

Huge unmet clinical challenge
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4. Staff and Client Attitudes

• Staff rated nic add. treatment significantly less
  important than treatment of other substances
• 53 staff thought addressing smoking should be
  put off until late or after a clients primary
  addiction treatment
• Only 29 thought it should be addressed early in
  treatment
• But nearly half of clients thought it should be
  addressed early in treatment
• Staff confidence rating for helping client who
  wanted to quit 7 (10 point scale) but varied
  considerably

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Steps being taken

• Assessing evidence on treatment of smoking and
  illicit drugs
• Improving recording and referrals in line with
  new SLaM systems
• Reorientation of the Maudsley Specialist Smokers
  Clinic

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Conclusions

• Strong relationship between smoking and use of
  other substances
• Motivation to stop is apparent but not being
  addressed
• Need to treat substances concurrently (e.g.
  Becker et al, 2013)
• Staff who smoke more likely to question
  importance of tobacco treatment, so no. of staff
  smoking is a concern for their own and patients
  health
• Introducing mandatory training and care pathways
  within SLaM to address concerns and also NICE
  guidance

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Harm Reduction for Smoking?

• Nicotine is largely why people smoke
• But its the other smoke constituents (CO, tar
  etc) that cause the death and disease

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Rationale for Harm Reduction Nicotine Harm
Continuum
E-cigs?
NRT
QUIT!
Most Dangerous
Least Dangerous
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Whats Needed?

• Develop clinical pathway to address the unmet
  clinical need
• Mandatory recording of smoking status
• Development of routinely provided support which
  should be documented in case notes
• Signpost specialist services
• NRT for withdrawal relief available to
  in-patients

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Clinically Significant Interactions with Tobacco

• Antidepressants
• Amitriptyline
• Nortriptyline
• Imipramine
• Clomipramine
• Fluvoxamine
• Trazodone

• Antipsychotics
• Clozapine
• Fluphenazine
• Haloperidol
• Olanzapine
• Chlorpromazine

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Other Clinically Significant Interactions with
Tobacco

• Heparin
• Insulin
• Warfarin
• Theophylline
• Propranolol
• Tacrine
• Acetaminophen
• Caffeine

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Recording and Monitoring
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Whats needed?

• Develop clinical pathway to address the unmet
  clinical need
• Staff training
• Support for staff smokers
• We are doing some qualitative research with staff
  to explore high levels of occasional smoking
  further

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What Can be Done Locally?

• Promote discussion around how your service can
  encourage and support smoking cessation
• Identify a smoking champion on the ward/service
• Routinely ask and record clients smoking status
  and motivation to quit
• Inform clients about pharmacological and
  behavioural support available as part of standard
  care and consider harm reduction for smokers who
  cannot or will not stop
• Identify where clients and staff can get support
  and clearly signpost this
• Encourage staff to complete relevant training
  (mandatory?)

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Acknowledgements

• Camilla Cookson
• All colleagues in the services in SLaM who
  supported the audit
• Karolina Bogdanowicz
• Prof John Strang
• Dr Elena Ratschen