Maximizing the Power of Partnerships: Engaging Smokers and the Mental Health Community

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Maximizing the Power of Partnerships Engaging
Smokers and the Mental Health Community

• Steven A. Schroeder, M.D., Director
• Smoking Cessation Leadership Center
• NCTOH, October 2007

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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 dental hygienists, nurses, physicians,
  respiratory therapists, physician assistants,
  pharmacists
• National smoking goals unachievable without
  involving mental health and substance abuse
  communities

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Trends in Adult Smoking, by SexU.S., 19552004
Trends in cigarette current smoking among persons
aged 18 or older
20.9 of adults are current smokers
Male
Percent
23.4
Female
18.5
Year
70 want to quit, including MH population
Graph provided by the Centers for Disease Control
and Prevention. 1955 Current Population Survey
19652001 NHIS. Estimates since 1992 include
some-day smoking.
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Smoking Prevalence Among Those with Mental Illness

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

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People with mental illness consume 44 of
cigarettes smoked in U.S.Breslau, 2003
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The Extraordinary Toll

• People with serious mental illness die 25 years
  earlier than the general population
• Most attributed to smoking, obesity, substance
  abuse, and inadequate access to medical care
• R. Manderscheid and C. Colton, April 2006, in
  Preventing Chronic Disease

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National Mental Health Partnership for Wellness
and Smoking Cessation

• Began at summit organized by the Smoking
  Cessation Leadership Center (SCLC) in March 2007
  in Virginia
• Intended to develop national consensus among key
  leaders in mental health and smoking cessation
  focused on need to
• Increase opportunities for wellness among mental
  health consumers and staff
• Ensure that smoking cessation treatments and
  tools are readily available

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National Mental Health Partnership for Wellness
and Smoking Cessation

• Members include
• 26 organizations and expanding
• National mental health advocacy, governmental,
  consumer, and provider organizations and smoking
  cessation experts
• 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 emphasize smoking cessation in
  all mental health service delivery settings.

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National Mental Health Partnership for Wellness
and Smoking Cessation

• Reasons for Partnership
• Approximately 50 of people with CMI are smokers
• People with mental illness smoke almost half of
  all cigarettes produced and are half as likely to
  quit as smokers without mental illness
• People with mental illness live 25 years fewer,
  on average, than the general population
• Nearly half of all deaths from smoking occur
  among people with mental illness
• For more information, please visit
  http//smokingcessationleadership.ucsf.edu/MH_Part
  nership.html

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http//smokingcessationleadership.ucsf.edu

• Special thanks to Eric Heiligenstein, M.D.
• Clinical Director, Psychiatry Service
• University Health Services
• Associate, CTRI
• University of Wisconsin-Madison

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2007 National Conference on Tobacco or Health
(NCTOH)

• Robert W. Glover, Ph.D.
• National Association of State Mental Health
  Program Directors (NASMHPD)

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NASMHPD

• Represents the 27.3 billion public mental health
  delivery system serving 6.1 million people
  annually in all 50 states, 4 territories, and the
  District of Columbia.
• Affiliation with the approximately 220 state
  psychiatric hospitals

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People with Serious Mental Illness Experience 25
Years Lost Life

• Smoking
• Obesity
• Substance Abuse
• Inadequate Medical Care

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USA Today Front Page Thursday, May 3, 2007
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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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Smoking Policies in State Psychiatric Hospitals

• 20 do not allow smoking at all
• 35 allow smoking on units
• 19 allow an unrestricted number of smoke breaks
• 23 are planning to change to more restrictive
  policies
• 35 have more permissive policies for staff
• NASMHPD Research Institute, Inc. July 2005

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Challenges Questions and Answers

• Smoke breaks are one of the few opportunities we,
  as consumers, have to relate to staff as peers.
  Besides, smoking is our only pleasure. How can
  you take that away?
• We appreciate that you want to spend time with
  staff outside of treatment. And we want to
  create healthy ways to do that. Smoking is an
  addiction. As a treatment facility, we can no
  longer support addiction by condoning smoking by
  consumers or staff. Furthermore we will work
  together, consumers and staff, to create new
  activity choices and opportunities that are both
  fun and healthy.

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Questions and Answers (cont.)

• Smoking calms down consumers. When they cant
  smoke, wont we experience complete mayhem?
• Banning smoking in psychiatric hospitals actually
  reduces mayhem. Facilities that do not allow
  smoking report fewer incidents of seclusion and
  restraint and reduction in coercion and threats
  among patients and staff.

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Questions and Answers (cont.)

• Smoking is a personal choice. How can you take
  that away without some serious collective
  bargaining?
• Historically unions have fought for safe working
  conditions. Internal documents show that tobacco
  companies have strategically marketed worker
  messages expounding upon the right to smoke.
  Yet, knowing cigarettes are loaded with toxic
  chemicals including 60 known carcinogens, Id
  rather we expend out energy working together on
  safety and health.

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• Objectives
• Recently Developed Resources
• Cessation Study Partnership
• with the Colorado QuitLine
• Next Steps with Primary Care

Chad Morris, PhD University of Colorado at Denver
and Health Sciences Center, Department of
Psychiatry
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The Colorado Model

• 2004 2006 Statewide Focus Groups
• Prevalence Studies
• Toolkit for Mental Health Providers
• Wellness Group Manual
• Randomized Study of Cessation Strategies
• Primary Care Training
• Other Disparities Groups

The UCDHSC Team Chad Morris, Ph.D. Jeanette
Waxmonsky, Ph.D. Mandy Graves, MPH Alexis Giese,
M.D. Olga Belikova
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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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Wellness Group Kit for Persons with Mental
Illnesses Promoting Recovery and
Wellness Clinician Guide

• Based on the Australia SANE model
• Based on Motivational Interviewing and Cognitive
  Behavioral Techniques
• 10 sessions / group format
• Structured framework with homework activities

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The Study Intervention (N 123)
Week 0 Entry/ Consent
Month 3
Month 15
Week 2
Month 12
Prescreening
Clinical Assessment Quitline
Clinical Assess. Quitline Group 1
Consult Quitline Psychoed Group 1
Clinical Assess. Quitline Group 2
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TrainingInitial Quitline Training

• Introduction to mental illnesses
• Unique challenge tobacco presents for persons
  with mental illnesses
• Evidence-based guidelines and treatment
• Cessation study
• Dialogue around the issues QuitLine staff face

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Next Steps

• Primary Care
• Pilot Study Analyses
• Expansion Current Study
• Peer-to-Peer Interventions
• Women and Smoking Cessation
• QuitLine / Wellness Group
• International

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Contact Information
Chad Morris, Ph.D. UCDHSC, Dept. of
Psychiatry Campus Box A011-11 4455 E. 12th
Ave Denver, CO 80220 (p) 303.315.9472 (f)
303.315.9343 chad.morris_at_uchsc.edu
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Maximizing on the Power of Partnerships Engaging
Smokers and the Mental Health Community
Reaching Consumers Training Psychiatrists
Jill Williams, MD Director, Division of Addiction
Psychiatry UMDNJ-Robert Wood Johnson Medical
School UMDNJ-School of Public Health
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Smoking Prevalence Rates
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Barriers to Addressing Tobacco in Mental Health

• Undervalue of tobacco use as a problem
• Consumers/ families minimize the health risks of
  tobacco
• Professionals/ MH systems have been slow to
  change in addressing tobacco
• Lack the knowledge about effectiveness of
  treatment
• Lack of advocating for treatment

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• Consumers Helping Others Improve their Condition
  by Ending Smoking
• Positive Message MH Consumers do have CHOICES

Williams JM. Using Peer Counselors to Address
Tobacco the CHOICES Program. Psychiatric
Services 2007 58(9) 1225
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CHOICES is a Partnership
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Using Peer Counselors to Address Tobacco among
Mental Health Consumers

• Employs mental health peer counselors to deliver
  the message to smokers with mental illnesses
• Addressing tobacco is important and that all
  smokers should seek treatment.

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Training Consumer Tobacco Advocates

• 30 Hours
• Tobacco Education
• Working with Smokers
• Advocacy
• Organizing events with agencies
• Ongoing supervision

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CHOICES Outreaches Consumers

• Mental health centers
• Self help centers
• Health fairs
• Transitional Housing
• Conferences

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Types of Contacts

• Group/ Health fair
• General education
• Information about CHOICES
• Individual/ Motivational
• CO Monitoring
• 20 min brief, personalized feedback

Move client from informal, group discussion to a
brief individual session
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Personalized Feedback

• Carbon Monoxide score and feedback
• Big impact on people
• Could see short-term benefits to quit
• Cost of Cigarettes for the year
• Tobacco caused medical conditions

Steinberg ML et al. JConsul Clin Psychology, 2004
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Carbon Monoxide Meters

• Cost 600-1500
• Cardboard mouthpiece
• Easy to use
• CO ppm (or COHb)
• Lights and tone

• Purposes
• Document smoke exposure
• Confirm abstinence
• Motivator

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CHOICES Resources

• Quarterly Newsletter
• Website (www.njchoices.org)
• Brochures, Handouts
• Tobacco Treatment Resource Directory

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CHOICES Newsletter
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www.njchoices.org
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Accomplished in First 2 Years

• Met with gt 3,660 consumers who smoke
• Made gt 133 community visits
• Gave the individualized peer to peer feedback
  session to gt 531 consumers who smoke
• Distributed newsletter to gt 740 consumers
  mental health agencies.
• Presented at 10 professional/ consumer
  conferences

Williams JM. Using Peer Counselors to Address
Tobacco the CHOICES Program. Psychiatric
Services 2007 58(9) 1225
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Research Study

• RWJMS IRB approved
• Subset of smokers who receive feedback
  intervention (n100)
• Incentive- phone card
• Baseline in-person survey
• 1 and 6 month follow-up phone survey
• Tobacco use Changes in smoking, use of treatment
• Satisfaction with peer contact

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Smokers in CHOICES Study (N102)
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Time to First Cigarette of Day
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Does your mental health program offer any tobacco
treatment?
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How easy was it to talk with a CTA about your
smoking compared to your psychiatrist/ mental
health professional?
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1 month Follow-up Results

• 86 response rate
• 30 reported trying to quit at 1 month follow-up
• 80 who had not tried to quit significantly
  reduced the number of cpd (11 vs 18 plt0.000)

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Reduced Access to Tobacco Treatment

• Tobacco dependence treatment should be given to
  all patients who smoke and are being seen by a
  psychiatrist
• APA Practice Guidelines for Treatment of Patients
  with Nicotine Dependence, 1996
• Nicotine dependence documented in 2 of mental
  health records
• Only 1.5 of patients seeing a psychiatrists
  received treatment for smoking

Peterson 2003 Montoya 2004
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Treating Tobacco Dependence in Mental Health
Settings

• A two-day training conference for Psychiatrists,
  Psychiatric Advanced Practice Nurses Other
  Mental Health Professionals
• Originally funded by American Legacy
• CME event
• November 2006 March 2007 to 71 participants

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Curriculum

• Targeting prescribers- assessments of dependence
  and use of pharmacotherapy
• Emphasized motivational techniques for lower
  motivated smokers
• Sections on neurobiological links between smoking
  and mental illness
• Systems change

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Training Evaluation

• Pre- and post-tests to evaluate knowledge
  acquisition
• Baseline survey of attitudes and beliefs.
• 69 (97) participated in evaluation
• 34 psychiatrists (49)
• 23 nurses (33)
• 5 psychologists (7)
• 6 counselors/social workers (9)

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Pre Post-Test Scores
Overall significant increase in scores by 6.38
points ( p lt0.0001)
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Survey Results
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Conclusions

• Peer to peer interventions have advantages for
  education and outreach to MI smokers
• Professionals have interest but need more
  training to effectively treat tobacco

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TREATING TOBACCO DEPENDENCE IN MENTAL HEALTH
SETTINGS

• Two-day training for Psychiatrists, Advanced
  Practice Nurses Other Mental Health
  Professionals
• November 2 and 3, 2007
• March 7 8, 2008
• New Brunswick, NJ
• http//rwjms.umdnj.edu/addiction/Training
  Programs.htm

Sponsored by UMDNJ-RWJMS, Division of Addiction
Psychiatry Phone [phone]
E-mail szkodnna_at_umdnj.edu
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Integrating Tobacco Dependence Treatment into
Mental Health Care A Motivation Based Approach

• Marie Hobart, M.D.
• Director, Wellness Program Initiatives
• Assistant Professor, Department of Psychiatry
• University of Massachusetts Medical School
• Chief Medical Officer, Community Healthlink
• 508-860-1025

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UMass Tobacco Dependence Treatment and Research
Programs

• UMass Center for Tobacco Prevention and Control
• Quit Works
• Massachusetts Tobacco Treatment Specialist (TTS)
  Training and Certification Program
• UMass Department of Psychiatry
• Clinical, Research, Training, System
  Consultation
• Basic Science, Health Services, and Clinical
  Research
• Addressing Tobacco in Addiction MH Settings
  Agenda
• Community Partnership Programs RWJF, MA State

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Treating Tobacco in Addiction and Mental Health
Settings

• Treatment can Work
• 5 NRT options, Bupropion, Varenicline
• Brief personalized feedback, education /
  counseling, MET, and Behavioral therapy
• Fewer Studies of Nicotine Dependence and either
  Mental Illness or other Addictions
• Abstinence versus Harm Reduction
• Motivation Based Treatment Approach total
  abstinence may not be immediately achievable

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Common ways to address tobacco in your mental
health clinic

• Clinically
• Motivation based treatment
• Education at minimum Personalized Feedback
• Medications and Therapy
• Environmental Tobacco Issues
• Forced abstinence inpatient - maintenance on NRT
• Smoking in designated places at designated times
• trigger monitoring and management
• opportunities for behavioral disconnects
• Staff Training EAP help for staff who smoke
• Policy issues chart templates, require
  documentation, no staff-patient smoking, get CO
  monitor for units, etc

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Motivation Based Treatment Approach

• Engagement Empathy
• Match Goals and Techniques to 5 Stages
• Precontemplation, contemplation, preparation,
  action, and maintenance
• Services matched to motivational levels
• healthy living groups (Williams, et al)
• contemplation vs action phase specific treatments
• Link with Co-Occurring Disorder treatments
• Nicotine Anonymous

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Helping Less motivated patients Abstinence
versus Harm Reduction

• Abstinence oriented studies patients are able to
  reduce the quantity and frequency of use
• Many Mental Health staff prefer harm reduction
  approaches
• Few formal studies of either long-term
  short-term harm reduction options
• Clinical harm reduction approaches tried
• reducing number of cigarettes
• switching some NRT for some cigarettes
• Long term NRT maintenance usage
• behavioral disconnects (not smoke in house, in
  car, etc)
• Concern compensatory change in smoking style to
  keep same nicotine levels track biomarkers (CO
  or cotinine levels)

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Addressing motivation

• Brief Interventions to increase motivation to
  seek treatment
• Brief Personalized Feedback
• Motivational Interviewing
• Healthy Living Group Based and individual
  treatments to provide education and increase
  motivation to quit smoking

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Healthy Living Groups

• Learning about Healthy Living group treatment
• Educational and motivational based intervention
• Open ended format, rolling admission, and not
  time limited
• Overall goal gain knowledge and live a healthier
  lifestyle
• Sessions
• information about risks associated with smoking
• what is in a cigarette, benefits of quitting,
  ways to quit smoking, and general health
  lifestyle behaviors to assist in quitting.
• Learn about related issues
• nutrition, physical activity, and stress
  management
• Clinical Educator Model of group facilitation
• utilizing role-plays, concrete examples,
  exercises, and questions to assess learning. 20
  Sessions in manual.
• CO Monitoring
• Principals can also be used in individual
  counseling as well

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Smoking Cessation Groups for individuals with
Schizophrenia

• Work with Eden Evins at our Community Health
  Link site
• Group Support and Bupropion/NRT
• Many can quit however difficult to sustain.
• From clinical experience, long-term outcomes
  improve with chronic treatment a model similar
  to treating psychiatric disorders
• Evins, Cather, Culhane, Birnbaum et al, 2007

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Tobacco Smoking Effects Some Psychiatric
Medication Blood Levels

• Smoking induces the P450s 1A2 isoenzyme
  secondary to the polynuclear aromatic
  hydrocarbons
• Smoking increases the metabolism of some
  medications
• Haldol, Prolixin, Olanzapine, Clozapine,
  Mellaril, Thorazine, etc
• Caffeine is metabolized through 1A2
• CHECK for medication SE or relapse to mental
  illness with changes in smoking status
• Nicotine does not change medication blood levels
  (2D6)
• NRT doesnt effect medication blood levels
• Nicotine may modulate cognition, psychiatric
  symptoms, and medication side effects

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Tactics of Treatment

• Medications
• Start Bupropion two weeks prior to quit date
• Start NRT Patch on quit date
• PDR versus Clinical Practice
• Use of NRT prior to quit date as a replacement
  for cigarettes
• Use of Bupropion plus patch (plus gum, etc)
• Dosage of NRT
• Use of multiple NRT strategies (multiple patches,
  multiple NRTs)
• Length of time on NRT or Bupropion

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Other Tactics

• Primary Psychiatric or other Addiction Medication
  choice
• Intensity and type of psychosocial treatments
• Tobacco Metabolism and Medications
• Monitor side effects and dosage
• Ongoing monitoring and reassessment
• Critical periods first three days, first two
  weeks and first six months
• CO, cotinine, and self-report of tobacco usage

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NRT for Schizophrenics

• More research needed placebo controlled
• NRT in variety of routes of administration,
  variable doses and duration for schizophrenic
  patients
• Higher dose transdermal patch (42mg) and trials
  of longer duration (24 weeks) Jill Williams et
  al, 2004
• In heavy smokers, under dosing may be one of the
  reasons for the limited efficacy of transdermal
  nicotine
• Blood cotinine levels at baseline and steady
  state measures for assessing adequacy of nicotine
  replacement

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Nicotine Nasal Spray for Schizophrenia

• NNS Rapid onset of action, intermittent dosing,
  and more immediate craving relief
• Case series 12 schizophrenic smokers
• failed prior treatments
• well tolerated, 75 used at least 30 sprays per
  day, 25 continuously abstinence, 40 were three
  months abstinent, 25 substantial CO lowering
  (21 to 3)
• The mean length of time with NNS was 255 days
  (range 2-811 days) and several used it for months
  prior to achieving abstinence
• Williams, Ziedonis, Foulds, 9/04, Psych Services

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Long-term NRT

• The long term health effects of NRT are unknown
• Felt to have less risk than chronic exposure to
  carbon monoxide and carcinogens.
• Long term use of the patch has not been a
  problem.
• Gum is almost never misused, thus lacking true
  abuse liability
• Weaning of the gum usually requires only
  education and reassurance even in long term
  users.

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What is a Clubhouse?

• Basic Components of a Clubhouse
• Work-Ordered Day, Employment, Evening, Weekend
  and Holiday Programs, Community Supports,
  Supported Education, Housing Support or Services,
  Outreach, Choice, Clubhouse Administration
  Operation, and Membership
• Provide a variety of services and supports
• Employment, Community Support Services, Outreach,
  Education, Housing, Health Promotion Activities,
  Advocacy, and Social Supports
• Organized internationally by the International
  Center for Clubhouse Development (ICCD)

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Genesis Club

• Founded on the realization that recovery from
  serious mental illness must involve the whole
  person in a vital and culturally sensitive
  community
• A restorative environment
• A partnership model with membership rights

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The Genesis Wellness Project

• 6 week structured exercise program as part of a
  wellness program at Genesis Club, Worcester MA
• Members (N17) had significant improvements in
  aerobic capacity (p0.0014) and perceived mental
  health (p0.046)
• Positive trends in perceived improvements in
  physical and social functioning.
• Qualitative data highlighted the value of group
  support and greater attention to nutrition as
  part of future programming.
• Pelletier, Ngyuen, Bradley, Johnsen, McKay, 2005

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Health Promotion in Clubhouse Programs Needs,
Barriers, and Current Planned Activities

• A survey examining perceptions of the need for
  health promotion interventions, current and
  planned health promotion practices, and barriers
  to change and program development in ICCD
  clubhouses.
• The mean number of health promotion activities
  ICCD clubhouses (N 219) report providing was
  5.24.
• Despite barriers (e.g., cost), results indicate
  that every clubhouse responding to this survey
  offers at least one health promotion activity.
• Clubhouse directors rated nutritional education
  and smoking cessation as items with the greatest
  need for health promotion interventions for
  clubhouse members.
• McKay Pelletier, 2007

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American Psychiatric Association Treatment
Guidelines

• Treatment Guidelines for Psychiatric Disorders,
  including Substance Use Disorders and Nicotine
  dependence
• www.psych.org
• call APPI press 1-800-368-5777
• Nicotine Dependence Guidelines in August 2006 AJP

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http//smokingcessationleadership.ucsf.edu