Increasing Access to Tobacco Cessation Services for People in Mental Health

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Increasing Access to Tobacco Cessation Services
for People in Mental Health The Time is Now

• Smoking Cessation Leadership Center
• Access 2008 Building a Tobacco-Free Future
• March 26, 2008

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The Smoking Cessation Leadership Center

• Began in 2003 as a Robert Wood Johnson National
  Program Office with a 10-million, five-year
  grant
• Aimed at helping clinicians do a better job
  intervening with tobacco users
• Additional funding from VA, American Legacy
  Foundation
• New foray into behavioral health arena, from
  Legacy grant

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SCLCs Aim

• We want more people who want to quit smoking to
  get the help and support they need to succeed
• Access to cessation tools and resources needs to
  be widened for all groups
• Health care providers have a special role, as the
  many partners we have already enlisted will
  attest
• Examples nurses, dental hygienists, physicians,
  respiratory therapists, physician assistants,
  pharmacists, peer specialists

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What Has Been Our Strategy?

• Make cessation intervention simpler, more
  concrete and easier to do, as embodied in Ask
  Advise Refer and the wallet card
• Work as members of nonhierarchical,
  results-driven, data-supported partnerships
• Spread the word through the channels of our
  partners and through our own connections

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Our Partners

• Ten formal partnerships with professional
  organizations or groups of organizations
• Family physicians, physician assistants,
  emergency physicians, anesthesiologists,
  respiratory therapists, dental hygienists,
  nurses, pharmacists
• including National Mental Health Partnership for
  Wellness and Smoking Cessation
• Five institutional/other projects
• JCAHO, Kaiser, VA, Make It Your Business/Step
  Up!, Its Quitting Time, LA, Chicago Second
  Wind Smoking Cessation Initiative, Washington
  Quits!

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One Example -- The American Dental Hygienists
Association (ADHA) Smoking Cessation Initiative

• Baseline and Target
• Baseline 25 in 2001 Journal of Dental Hygiene
  study (Winter 2001)
• Increase to 50 the percentage of dental
  hygienists that screen their clients regarding
  tobacco use (rate, type and amount) by 2006.

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Ask. Advise. Refer. 5 As
Ask
Ask. Every patient/client about tobacco use.
Advise
Assess
Assist
Advise. Every tobacco user to quit.
Arrange
Refer. Determine willingness to quit. Provide
information on quitlines.
Refer to Quitlines
ADHA Smoking Cessation Initiative (SCI)
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National Survey Results

• 56 of dental hygienists offer cessation
  treatment at every or most visits
• 71 intervene with higher risk clients
• 78 of those respondents who had accessed the AAR
  website had incorporated cessation information
  into practice

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American Academy of Family Physicians
What percentage of your patients do you (or our office staff) ask about tobacco use? What percentage of your patients do you (or our office staff) ask about tobacco use? What percentage of your patients do you (or our office staff) ask about tobacco use?
Ask Pre-campaign Post-campaign
80-100 81 91
60-79 11 7
40-59 5 1
0-39 3 1
No response N/A 1

• 390,000 cards distributed

For what percentage of your patients who use tobacco do you use the Five A's (Ask, Advise, Assess, Assist Arrange) to encourage cessation? For what percentage of your patients who use tobacco do you use the Five A's (Ask, Advise, Assess, Assist Arrange) to encourage cessation? For what percentage of your patients who use tobacco do you use the Five A's (Ask, Advise, Assess, Assist Arrange) to encourage cessation?
5As Pre-campaign Post-campaign
80-100 28 33
60-79 22 19
40-59 15 11
0-39 34 36
No response 1 1
Could referring patients to a free telephone quitline increase your ability to provide cessation counseling? Could referring patients to a free telephone quitline increase your ability to provide cessation counseling? Could referring patients to a free telephone quitline increase your ability to provide cessation counseling?
Quitline Pre-campaign Post-campaign
Yes 44 53
No 13 10
Not sure 43 36
No response 1 1
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American Society of Anesthesiologists
2007 Pilot Study 8 of 14 sites
Anesthesiologists referring smokers pre-op to
quitlines
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Why Our Focus on Mental Health?

• Prevalence is 75 percent for those with either
  addictions and/or mental illness, as opposed to
  20.9 percent for the general population
• In mental health settings, about 30-35 percent of
  the staff smoke

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• People reporting a mental disorder in the past
  month consumed approximately 44.3
  of all cigarettes
  smoked in the U.S.
  

Lasser, Karen Boyd, J. Wesley Woolhandler,
Steffie Himmelstein, David U. McCormick, Danny
Bor, David H., "Smoking and mental illness A
population-based prevalence study." JAMA, The
Journal of the American Medical Association.

Nov 22-29, 2000, 284, (20), 2606 - 2610.
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Rates of smoking are 2-4 times higher among
people with psychiatricdisorders and
substance use disorders.
Kalman D, Morissette SB, George TP. American
Journal on Addictions. 2005, 106-123.
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Major depression 50 to 60
Anxiety disorder 45 to 60 Bipolar
disorder 55 to 70 Schizophrenia
65 to 85
Smoking Prevalence among People with Mental
Illnesses
20 of those with schizophrenia started smoking
at college age and many began smoking in mental
health settings receiving cigarettes for good
behavior.

• Presentation at the NASMHPD Medical Directors
  Council Technical Report Meeting on Smoking
  Policy and Treatment at State Operated
  Psychiatric Hospitals, April 20-21, 2006, San
  Francisco, California. DeLeon et al., in press.

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Rates of smoking among treatment staff in mental
health and substance abuse facilities and
programs are higher than other health care
professionals
30-35 of Mental Health Providers Smoke
Primary Care Physicians 1.7 Emergency
Physicians 5.7 Psychiatrists 3.2
Registered Nurses 13.1 Dentists 5.8
Dental Hygienists 5.4 Pharmacists 4.5

• NASMHPD Research Institute, Inc. (2006). Survey
  on Smoking Policies and Practices for Psychiatric
  Facilities.
• Strouse R, Hall J and Kovac M. Survey of
  Health Professionals' Knowledge, Attitudes,
  Beliefs, and Behaviors Regarding Smoking
  Cessation Assistance and Counseling. Princeton,
  N.J.
• Mathematica Policy Research, Inc., 2004, 1-16.

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41 of state psychiatric facilities are smoke-free

• NASMHPD Research Institute, Inc. (2006). Survey
  on Smoking Policies and Practices for Psychiatric
  Facilities. Presented by Joe Parks, M.D. at the
  NASMHPD Medical Directors Council Technical
  Report Meeting on Smoking Policy and Treatment at
  State Operated Psychiatric Hospitals.

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A Targeted Population

• As smoking prevalence declines, a greater
  proportion of smokers are in this population
• Tobacco companies actively target the mentally
  ill and substance abusers
• This is proven through tobacco papers (Project
  SCUM)

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Behavioral Causes of Annual Deaths in the United
States, 2000
435
Number of deaths (thousands)


112
Sexual Alcohol Motor Guns
Drug Obesity/ Smoking Behavior
Vehicle
Induced Inactivity
Source Mokdad et al, JAMA 20042911238-1245
Mokdad et al JAMA. 2005 293293 Flegal
KM, Graubard BI, Williamson DF, Gail, MH. Excess
deaths associated with underweight, overweight,
and obesity. JAMA 20052931861-1867
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Another Eye-Opening Study

• New NASMHPD study Morbidity and Mortality in
  People with Serious Mental Illness, showed
  25-year gap in life expectancy

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USA Today Front Page Thursday, May 3, 2007
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History in Mental Health Outreach

• Bob Glover, executive director of NASMHPD, asked
  Steve to present at the NASMHPD Directors Meeting
  (2004) in San Francisco
• Interest among the MH community in doing
  something about tobacco was growing

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A Fortuitous Referral

• In 2005, RWJF sent us a query for funding from
  Joe Parks , NASMHPD, Medical Directors Council
• Led to a grant to fund a meeting around making
  state psychiatric facilities smoke free
• Summit convened 15 commissioners and state
  medical directors with NASMHPD in San Francisco
  (April 2006) and led to the
• Technical Report on Smoking Policy and Treatment
  in State Operated Psychiatric Facilities

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The Legacy Grant

• Legacy offered SCLC three years of funding
  largely to focus on mental health, as well as to
  expand our current efforts
• Official project was launched in July 2006

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Summit in Lansdowne

• Held March 22-23, 2007 in Lansdowne, Va.
• Brought together 24 partners including leading MH
  organizations such as NASMHPD, NAMI, MHA, etc.
• Included cessation and quitline experts and SCLC
  staff

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New Partnership was Born

• The National Mental Health Partnership for
  Wellness and Smoking Cessation
• 28 Partners
• SCLC providing administrative support and a
  series of small grants to various MH participant
  organizations

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The Mental Health Partnership

• American Legacy Foundation
• American Psychiatric Nurses Association
• American Psychiatric Association
• Association for Behavioral Health and Wellness
• Bazelon Center for Mental Health Law
• Behavioral Health Policy Collaborative
• California Smokers Helpline
• Campaign for Mental Health Reform
• Carter Center Mental Health Program
• Depression and Bipolar Support Alliance
• Mental Health America
• Mental Health Association of Southeastern PA
• National Alliance on Mental Illness
• National Association of County Behavioral
  Healthcare Directors
• National Association of Psychiatric Health
  Systems
• National Association of Social Workers

• National Association of State Mental Health
  Program
• Directors (NASMHPD)
• NASMHPD National Research Institute
• National Council of Community Behavioral
  Healthcare
• National Empowerment Center
• Ohio Department of Mental Health
• Robert Wood Johnson Foundation
• Substance Abuse and Mental Health Services
• Administration/Center for Mental Health
  Services
• Smoking Cessation Research and Policy Center at
• Oregon Health Science University
• Smoking Cessation Leadership Center
• University of California San Francisco Department
  of
• Psychiatry
• University of Massachusetts Memorial Medical
  Center

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Mission Statement

• We the undersigned resolve to bring forth and
  lead a national partnership campaign to make
  health and wellness a priority for people with
  mental illnesses and for the providers who serve
  them. As a first and immediate focus, we commit
  ourselves to addressing the serious consequences
  of smoking and to emphasizing smoking cessation
  in all mental health service delivery settings.

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Action Plan

• Promote consumer-driven education
• Promote provider-motivated education
• Promote staff wellness and smoking cessation
• Outreach to key players and stakeholders
• Build infrastructure
• Assess and strengthen effectiveness of quitlines
  with consumers and staff
• Develop data on smoking rates and behaviors

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SCLC Grant Recipients

• American Psychiatric Nurse Association
• Depression and Bi-Polar Support Alliance
• Mental Health America
• National Association of State Mental Health
  Program Directors (NASMHPD)
• NASMHPD, National Research Institute
• National Council for Community Behavioral
  Healthcare
• University of Colorado at Denver

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Progress to date

• Data is being collected
• Concrete tools are being created
• Presentations to draw awareness
• Website is being created to house all resources
• Partnership Communiqué

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Data committee NASMHPD, National Research
Institute

• Collect data on smoking cessation from
  Partnership constituent chapter organizations
  (MHA, NCCBH etc.)
• Will capture first hand accounts of the smoking
  and non-smoking policies of state psychiatric
  facilities
• Develop survey to address client care in relation
  to seclusion and restraint figures, aggression,
  and elopement, to name a few, and
• Assess impact of employee smoking policy on staff
  activities.

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Depression and Bi-Polar Support Alliance

• Surveying membership to create smoking cessation
  tools for consumers
• Developing curriculum and materials to teach
  certified peer specialists to become tobacco
  interventionists using Rx for Change
  Ask-Advise-Refer
• Finding an inroad to get Medicaid reimbursement
  for mental health professionals

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NASMHPD

• Developed technical assistance tool kit
  addressing how to implement smoking cessation in
  psychiatric hospital settings
• Featured smoking cessation as a plenary topic
  during its recent National Summit of State
  Psychiatric Hospital Superintendents
• Promoted 1-800-QUIT NOW

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• Assessment and Intervention Planning
• Readiness to Quit and Stages of Change
• Cultural Considerations
• Smoking and Psychiatric Illness Nicotine Effects
  and Other Considerations
• Smoking Cessation Treatment for Persons with
  Mental Illnesses
• Behavioral Interventions for Smoking Cessation
• Prescribing Cessation Medications
• Relapse Prevention
• Local and National Tobacco Cessation Resources
• Toolkit References
• Literature Review

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National Council for Community Behavioral
Healthcare

• Held a workshop on smoking cessation at its
  national conference
• Surveying members to identify baselines and gaps
  in provider knowledge, in partnership with NRI

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BEA Resource Guide

• Bringing Everyone Along Resource guide was
  developed by the Tobacco Cessation Leadership
  Network, is now available to download from the
  TCLN website at www.tcln.org.
• Compilation of the existing evidence base,
  professional experience and advice, and emerging
  resources
• Developed to assist a diverse array of health
  professionals to tailor tobacco cessation
  services to meet the unique needs of tobacco
  users with mental health or substance abuse
  disorders

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American Psychiatric Nurses Association

• Summit held Feb. 14-16, 2008
• 15 leaders in psychiatric nursing
• Baseline is
• 61 of Psych Nurses do brief interventions (AAR )
• 29 of Psych Nurses do intensive (5As)
• Target is to increase both categories by 5 each
  year
• Action plan
• Raise awareness
• Partner with States
• Establish an education forum and media campaign

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Resources

• Quarterly Newsletter
• Brochures, Handouts
• Tobacco Treatment Resource Directory
• CE training for MH providers-UMDNJ-Robert Wood
  Johnson Medical School
• Articles and Publications
• www.njchoices.org

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Other Partners Also Stepping Up

• National Association of Psychiatric Health
  Systems
• Presentation to about two hundred NAPHS
  administrators on smoking cessation via
  conference call in July 2007

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National Mental Health Consumer Self-Help
Clearinghouse

• Devoted the lead story in its recent newsletter
  to smoking cessation.

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Momentum in Other Avenues

• Presentations in
• National Conference on Tobacco or Health 07
• American College of Mental Health Administrators
• National Alliance on Mental Illness
• Society for Research on Nicotine and Tobacco
• Society for Behavioral Medicine

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The Partnership Communique

• Originally designed to keep partners connected
• Growing interest has expanded the list to all who
  are interested or have something to add
• Submit updates to csaucedo_at_medicine.ucsf.edu

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The Partnership Website
Resources include presentations, publications,
smokefree facilities toolkit, provider toolkit,
partnership communiqué and awareness posters and
video
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Next Steps

• Disseminating tools of best practices
• Learning more about how quitlines can interface
  with the mental health population
• Addressing issues for staff as well as consumers
• Maintaining momentum
• Adding partners

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What can you do?

• Use these resources
• Refer your colleagues
• Sign up for the MH Communiqué
• Refer staff and patients to 1 800 Quit Now
  or local services

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Major Unresolved Questions

• Best time to quit? Is depression stabilization
  needed?
• What about co-morbidities? (Alcoholics who quit
  smoking are more likely to stay sober)
• Long-term cessation rates for smokers with mental
  illness versus non-mentally ill population?
• Risk of cessation exacerbating underlying CMI?
• How better engage the mental health treatment
  community? The NIH?
• How help mental health workers quit?
• Efficacy of quit lines and internet?
• Role of non-mental health clinicians (e.g.,
  primary care)?

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Power of Intervention

• ? to ½ of the 44.5 million smokers will die from
  the habit. Of the 31 million who want to quit, 10
  to 15.5 million will die from smoking.
• Increasing the 2.5 cessation rate to 10 would
  save 1.2 million additional lives.
• If cessation rates rose to 15, 1.9 million
  additional lives would be saved.
• No other health intervention could make such a
  difference!

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Final Thoughts

• Smoking in patients with mental illness is a
  hidden epidemic with a huge human toll.
• The mental health treatment culture is just
  beginning to address this issue.
• Many patients would like to quit, but it is not
  easy.
• Five As not producing rapid results.
• More medications being developed.
• Few clinical situations present such an
  opportunity to improve health!

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Thank You!

• Catherine Saucedo,
• Director of Strategic Marketing
• csaucedo_at_medicine.ucsf.edu
• [phone]
• Reason Reyes,
• Technical Assistance Manager
• rreyes_at_medicine.ucsf.edu
• [phone]
• http//smokingcessationleadership.ucsf.edu