Meeting the Challenges of Behavioral Health Smokers: Smokers Living with Serious Mental Illness

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1 Meeting the Challenges of Behavioral Health Smokers: Smokers Living with Serious Mental Illness Melanie Bennett, Ph.D. Professor, Department of Psychiatry, UMSOM Research Health Scientist, VAMHCS Associate Director for Education, VISN 5 MIRECC Presentation for the 12 Annual MDQUIT Best Practices Conference January 18, 2018

2 Acknowledgements University of Maryland School of Medicine Department of Psychiatry and the VISN 5 MIRECC Alan Bellack, Alicia Lucksted, Clay Brown, Deb Medoff, Amy Drapalski, Richard Goldberg, Julie Kreyenbuhl, Jason Peer, Julia Evelly, Aditi Vijay, Wendy Potts, Marlon Tinker, Bernadette Guthrie, Viara Quinones-Jackson, Matt Kendra, Josh Clark, John Freimuth, Wylla Jackson, Elana Schwartz, Ashley Prince, Belinda Kauffman, Jeanette Robinson, Lan Li, Reginald Cunningham, Ali Saperstein, Katiah Llerena, Mike Early, Camille Wilson, Elera Nwogu, Jay Prochaska, Cindy Clark, Julia Surrow, Beth Klingaman, Asia Malik, Elana Schwartz, Erica Travers, Ashely Prince, Julie McCarthy, Thomas Tsuji, Michele Crisafulli, Lache Wilkins, Gabriella Coakley Other Institutions Faith Dickerson, Lucy Billiter - Sheppard Pratt Lisa Dixon - Columbia Carlo DiClemente - UMBC Funding - research grants from: NIMH (1 R34MH A1, Bennett PI) VA CSR&D (1I01CX A1, Bennett PI) NIH/NIDA (1R34 DA , Dickerson, PI) 2

3 Smoking and Quitting National Institute on Drug Abuse, American Lung Association Cigarette smoking kills an estimated 440,000 U.S. citizens each year more than alcohol, illegal drug use, homicide, suicide, car accidents, and AIDS combined. Individuals with psychiatric disorders purchase approximately 44 percent of all cigarettes sold in the United States, which undoubtedly contributes to the disproportionate rates of morbidity and mortality in these populations. Extensive research has shown that treatments for tobacco addiction do work. It's never too late to quit smoking. 52 million Americans who used to smoke have now quit for good. Many had to try a few times, but they didn t give up and they are now smokefree.

4 Question 1 Why is quitting smoking important? Question 2 Why is quitting smoking hard? Question 3 What can we do to help SMI smokers prepare for and take steps towards quitting?

5 Question 1 Why is quitting smoking important? Tobacco smoke contains harmful chemicals. These chemicals are responsible for many health problems in Veterans and those who breathe in secondhand smoke. Increased risk of developing or having complications from: hypertension, cancer, diabetes, cardiac disease, lung and breathing problems, healing after surgery

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7 Smoking and Mortality in SMI Individuals with SMI die on average years earlier than those in the general population 1-6 from a range of chronic medical conditions Mortality is higher due to inadequate prevention, screening, and treatment of a range of early risk factors including smoking, obesity, physical inactivity, hypertension, and dyslipidemia Over 60% of SMI patients smoke; smoking contributes more to elevated mortality in SMI than antipsychotic treatment, metabolic disturbances, or weight gain Compared to other health behavior changes, early smoking cessation (SC) has the largest beneficial effect on later health 30-32, making smoking an important target for services that, if effective, can lead to improved health and reduced mortality.

8 Smoking: Young Adults living with SMI 40-60% of young adults with SMI smoke Young adults with SMI have been smoking for, on average, over 5 years 23. While use of alcohol and other drugs decreases over time in young adults with SMI, rates of smoking remain high 24. Srihari and colleagues 25 compared 76 young adults with early psychosis to age-matched controls on rates of cardiometabolic health risk factors assessed three times over one year. 44% in the SMI group were smokers at baseline (compared to 33% in the non-smi group); this increased to 68% at the 1-year assessment. Table 1: Current Smoking by Age; Maryland Public Behavioral Health System, FY15 Age % Age %

9 Question 2 Why is quitting smoking so hard? Change is hard for everyone, even when we know we should change and even when we really want to change. Smoking is a habit that s hard to break.

10 Cessation Challenges Smoking is a useful coping strategy Smoking is a hard habit to change Ambivalence Low confidence History of failure Lack of support Don t know how to change Others around me smoke Pre-contemplation - Not ready Contemplation - Thinking about it Preparation - Getting ready Action - Making the change Maintenance - Sustaining change Recycling - Slipping back to old behaviors, need to start again

11 The Truth: People Improve their Health Every Day People regularly quit smoking People regularly lose weight and improve their dietary habits People regularly increase their level of physical activity

12 People with SMI Can Quit Smoking: Successful Quitters Study [Dickerson, Bennett et al. Psychiatric Rehab J : ] Sample: Persons with SMI who had been abstinent from smoking for >= 4 months Mean age: 50 (±9.5) years 60 % male; 72 % Caucasian Mean duration of smoking: 25.3 (±11.4) years Mean duration of current abstinence: 7.4 (±8.6) years Main strategies: social support from friends or family (58%); direction from a doctor (46%); use of nicotine replacement therapy (31%); advice of friends who had quit (23%)

13 Integrated Approach to SC in SMI (NIMH R34, Bennett PI, ) Consumers with SMI want to quit smoking Mean of 2.48 (sd=5.06, range 0-32) lifetime serious quit attempts 82.6% reported 1+ previous quit attempts of 24+ hours 63% had goal to quit and stay off forever 67% seriously considering quitting in the next 6 months 41% planning to quit in the next 30 days 57% extremely important to cut down/quit smoking Confidence is low 35% not at all or only somewhat confident On a 1-100% scale, 61% rated their confidence in being able to quit < 50% Only 28% extremely confident that they will succeed Norms / Support for quitting 29% report it s acceptable for adults to smoke, 50% don t care 66% reported 50%+ of the adults in my neighborhood smoke 87% reported 50%+ of the people at this PRP smoke Over 60% reported parents who are current/former smokers Over 55% reported friends who are current smokers

14 Question 3 What can behavioral health professionals do to help Veterans prepare to quit smoking? A lot at every stage of change! Help SMI smokers: 1. Talk about smoking and quitting 2. Practice new coping strategies 3. Get ready to quit 4. Sample quitting

15 Behavioral Treatment for Smoking Cessation Tailored Services for Smokers with SMI Session 1: Positive and negative aspects of smoking Session 2: Health benefits of quitting Session 3: Habits, cravings and triggers for smoking Session 4: High risk smoking situations Session 5: Coping with cravings Session 6: Avoidance and escape Session 7: General refusal skills/refusing cigarettes Session 8: Leaving a stressful situation Session 9: Asking for support from people as a nonsmoker Session 10: Coping with depression without smoking. Session 11: Coping with anxiety and stress without smoking Session 12: Coping with low motivation to quit. Session 13: Coping with boredom Session 14: Making small talk Session 15: Making plans with a friend Session 16: The biology of SPMI and smoking Session 17: Coping with symptoms and side effects I Session 18: Coping with symptoms and side effects II Session 19: Coping with lapses Session 20: Use of other substances as a smoking trigger Session 21: Coping with negative affect without smoking Session 22: Coping with other high risk smoking situations Session 23: Continued practice coping Session 24: Continued practice with coping 24 group meetings Individual motivational interview 2 weeks of engagementfocused outreach Education on and support for use of NRT Harm reduction model Nonjudgmental support for quitting Breath CO monitoring with feedback Skills training Goal-setting at each group meeting Ongoing assistance with use of NRT

16 Help SMI Smokers Talk about Smoking and Quitting

17 Talk about Smoking and Quitting Are you interested in talking today about quitting smoking? It is something I can help you with. How do you feel about trying to quit or changing your smoking? Has anyone talked to you about quitting smoking? There are lots of treatment resources. Why do you smoke? What s good about smoking? What purpose does it serve? Why change? What are important reasons for you? What obstacles will you face? Tools: Pros/Cons list

18 Pros and Cons List Feels good Pros of Smoking Helps me feel calm when I m upset Helps me cope Something to do Something I do to pass the time Something I do with my friends and family I enjoy smoking Cons of Smoking Makes it difficult to breathe My doctors and nurses have told me that my health problems are related to smoking Costs a lot of money Being a bad role model for my grandkids

19 Offer Facts about Quitting At every age, quitting increases your life expectancy. 24 hours after quitting, chances of having a heart attack decrease. Within a month or two you can feel your lungs working better, you have more energy and no more cough. Quitting will greatly lower your chances of having a stroke and getting cancer. The people you live with will be healthier. You will have money and time to spend on other things!

20 Help SMI Smokers Practice New Coping Strategies

21 Practice New Coping Strategies Talk about what helps the individual cope with stress Give suggestions and examples of activities the individual may not have tried before Meditation, deep breathing, other mindfulness strategies Expend energy (exercise, other ways to distract) Seek support, talk to someone Problem solve (review problem solving skills) Practice using these strategies in real life situations

22 Ways to Cope with Cravings Miss holding something? Hold a pencil, squeeze a ball Miss having something in your mouth? Chew gum, carry a water bottle, chew a toothpick Used to smoking after meals? Change your routine brush your teeth, go for a walk Around a lot of smokers? Spend time in nonsmoking places, keep away from people who smoke (temporarily) Worried about quitting on your own? Find someone to quit with you!

23 Help SMI Smokers Get Ready to Quit

24 Help the Individual Find Support What kind of support does this individual need? Practical? Emotional? Help the individual tell others that he/she is going to quit Practice ways to ask for help from others Friends, Family, Professionals, on line, SC groups

25 Make Suggestions Pay attention to when you smoke Write it down Use an app Look for patterns Try something new Identify a good time to quit

26 Smartphone Apps quitstart QuitNow

27 Help the Individual Make a Decision to Change Make a list of reasons for change Figure out what barriers stand in the way Make a list of helpful strategies What s helped in the past? What s helped others? Shore up support Make small changes PRACTICE change Smoking: It takes 5-6 tries before quitting for good so get started!

28 Help the Individual Build Confidence Confidence predicts success! Research shows that people who make changes believe that they can make changes. Need to think change is possible. What can I do? Make a plan to: Start easy Set small goals Understand that you will mess up sometimes

29 Other Ways to Help SMI Smokers Get Ready to Quit Know the available resources and how to refer to them. Give facts about NRT and how it helps people quit. Set up a time to a prescriber about NRT. Discuss past quit attempts What worked build on that What led to relapse plan for that

30 Help SMI Smokers Sample Quitting

31 Do Something To Change Cut down Not smoking in certain places Delay first cigarette of the day Change the environment Put up reminders Try NRT Patch, gum, lozneges Use on-line resources Learn your triggers What are your triggers? What can you do when faced with a trigger? Practice skills Have a plan: D-Pack Distract Delay Discuss Deep breathe Drink water

32 Select a Quit Date Help individual select a quit date Pick a date in the near future NOTE: A celebration date may be a trigger for smoking Remove all tobacco products Identify triggers he/she will experience that day For each, write down ways to cope without smoking Use the D-Pack: Distract, Delay, Discuss, Deep breathe, Drink water Offer support the day before, day of, and day after the quit date

33 Sample Quit Smoking Skills Irritable/anxious: Walk, bath, relaxation, deep breathing Down/depressed: Do something fun, see someone supportive Restless/trouble sleeping: Exercise, stay busy Hungry/weight: Drink water and low calorie drinks, eat low calorie snacks, chew gum Talk to your doctor about NICOTINE REPLACEMENT PATCH, GUM, LOZENGE

34 How To Set A Small Goal

35 Ways to Maintain Change Resources Rewards Nicotine replacement Counseling On line tools Self help groups and manuals ASK FOR HELP What s rewarding to you? Other ways to spend money Track positive health effects Share success with others

36 Cyclical Model of Change Many will recycle through multiple change attempts and multiple interventions. Successful change occurs for large numbers of people over time. Keys to successful recycling Persistent efforts Repeated contacts Bolster confidence and motivation

37 Summary Quitting smoking is important. Quitting can be hard. Change is possible! There are things you can do to help Veterans prepare to quit. There are things you can do one a Veteran is ready to quit.

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40 Smokefreevet Part of Smokefree.gov Quitting smoking is one of the best things you can do for your physical health, emotional well-being, and quality of life. Use SmokefreeVET s tools, resources, and support to help you become tobacco-free. Education on addiction and why people smoke Reasons for quitting How smoking improves health Text messages Speaking to an expert Facebook Build a quit plan Strategies for quitting Information on medications

41 Veterans Stay Quit Coach Features Educational materials about the benefits of quitting smoking, risks of smoking, medication and nicotine replacement and their efficacy in preventing relapse, and how to cope with urges Perspectives and coping tools for those who smoke after their quit date Access to support contacts or hotlines for preventing relapse Motivational messages and personalized information about the benefits of staying quit Reminders to take any medications or nicotine replacement therapies This App is meant to be used in conjunction with Integrated Care for Smoking Cessation. However, it provides instruction and information for those using it as a standalone tool to be able to do so independently with ease.

42 Other Resources American Lung Association: American Cancer Society: Centers for Disease Control and Prevention: MOVE - a national weight management program designed by the VA National Center for Health Promotion and Disease Prevention (NCP), a part of the Office of Patient Care Services, to help veterans lose weight, keep it off and improve their health: The Tobacco Dependence Program (TDP) at UMDNJ provides expertise on quitting smoking through education, treatment, research and advocacy: