Tobacco Use, Prevention, and Treatment Needs in Health Priority Populations

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2 Tobacco Use, Prevention, and Treatment Needs in Health Priority Populations H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration U.S. Department of Health & Human Services Strengthening APA s Role & Collaborations in Reducing Tobacco Health Disparities Washington, DC December 10,

3 Since at least the middle of the last century, we've known about the harmful and often deadly effects of tobacco products. More than 400,000 Americans now die of tobacco-related illnesses each year, making it the leading cause of preventable death in the United States. President Barack Obama June 22,

4 Kathleen Sebelius Secretary U.S. Department of Health & Human Services Sadly, we ve seen too many friends, families and communities suffer needlessly, and suffer tremendously, from tobaccorelated death, disease and disability. We have a clear path to ending the tobacco epidemic and it is a battle we can and must - win. The prosperity and health of our country depends on it. November 17,

5 Pamela S. Hyde, J.D. Administrator Substance Abuse and Mental Health Administration Smoking is the nation s leading cause of preventable death. We must pursue every opportunity to prevent the kids and young adults of today from becoming lifelong adult smokers of tomorrow, 5

6 The Challenge In 2011, an estimated 68.2 million Americans aged 12 or older were current (past month) users of a tobacco product approximately 26% of the population in that age range. 22.1% of past month cigarette smokers reported current use of an illicit drug, compared to 4.9% of persons who were not current cigarette smokers. Over half of the youths million youths years -- who smoked cigarettes in the past month also used an illicit drug (compared to 6.1% of youths who did not smoke cigarettes). Source: 2011 NSDUH 6

7 Past Month Tobacco Use among Persons Aged 12 or Older: Source: 2011 NSDUH + Difference between this estimate and the 2011 estimate is statistically significant at the.05 level. 7

8 Current Tobacco Use: Race/Ethnicity Current Tobacco Use among Persons 12 years and older: 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 13.0% Source: 2011 NSDUH 20.4% 26.2% 28.6% 36.1% Asians Hispanics Blacks Whites Two or More Races 43.0% American Indians/Alaska Natives 8

9 Past Month Cigarette Use among Women Aged 15 to 44, by Pregnancy Status: Combined Years to Source: 2011 NSDUH + Difference between this estimate and the estimate is statistically significant at the.05 level. 9

10 Alcohol and Cigarettes Alcohol Use Persons 12+ yrs. Current Cigarette Smokers Non-cigarette Smokers (Past month) Past Month Alcohol Use 66.5% 47.6% Binge Alcohol Use 42.5% 17.0% Heavy Alcohol Use 15.3% 3.6% Source: 2011 NSDUH 10

11 Source: 2011 NSDUH + Difference between this estimate and the 2011 estimate is statistically significant at the.05 level. 11

12 Smoking Prevalence: LGBT Populations As of 2012, no national survey that measures tobacco use also asks about sexual orientation or identity. HHS plans to add a question about sexual orientation to the 2013 National Health Interview Survey. Despite this lack of national data, it is believed that rates of cigarette smoking are higher in the LGBT population than in the general US population. A 2009 study estimated that LGBT women are 1.5 to 2 times more likely to smoke than heterosexual women. LGBT men are estimated to be 2 to 2.5 times more likely to smoke than heterosexual men. Source: American Legacy Foundation, July

13 Smoking Prevalence among Adults by Lifetime Mental Illnesses Compared to General Population Percentage of Smokers in general population 20.6% Percentage of Smokers among those with: Schizophrenia 59.1% Bipolar Disorder 46.4% Serious Psychological Distress 38.1% Attention Deficit Disorder 37.2% Dementia 35.4% Phobias or Fears 34.3% Source: McClave et al: Smoking characteristics of adults with selected lifetime mental illnesses: results from the 2007 National Health Interview Survey. American Journal of Public Health. 2010; 100:12.

14 Smoking Prevalence among Individuals with Substance Use Disorders Individuals attending substance abuse 77%* treatment Opioid-dependent individuals 92%** An estimated 44% of cigarettes sold in the U.S. are sold to smokers with mental illness or substance use disorders.*** Sources: *Kelly et al: Drug and Alcohol Review. 2012;31; **Brooner et al: Arch Gen Psychiatry. 1997;54: **Strain EC: Clin J Pain. 2002;18: *** Lasser et al, JAMA. 2000;284(20):

15 Effects of Increased Cigarette Prices Increases in cigarette prices lead to significant reductions in cigarette smoking. A 10% increase in price has been estimated to reduce overall cigarette consumption among adolescents and young adults by about 4%. Increases in cigarette prices can lead to significant reductions in smoking prevalence by increasing cessation among smokers and reducing smoking initiation among potential young smokers. Source: CDCP, Economic facts about U.S. tobacco production and use. ( accessed 11/21/12 15

16 Cigarette Prices and Cigarette Sales, Source: Preventing Tobacco Use among Youth and Young Adults: A Report of the Surgeon General, U.S. Dept. Health and Human Services, CDCP, 2012.

17 Source: Preventing Tobacco Use among Youth and Young Adults, a Report of the Surgeon General, CDC, July Effective Prevention Policies Policies proven to prevent young people from using tobacco: Make tobacco products less affordable. Restrict tobacco marketing. Ban smoking in public places (workplaces, schools, restaurants, hotels, parks, etc.) Require tobacco companies to label tobacco packages with large, graphic health warnings.

18 Behavioral Health Interventions Federal Government Tobacco Initiatives: 5 New Laws SAMHSA Tobacco Initiatives Treating Tobacco Use and Dependence: Key Findings 5 A s Model for Treating Tobacco Use/Dependence 7 FDA-Approved Tobacco Medications 18

19 Source: Ending the Tobacco Epidemic: Progress toward a Healthier Nation, August The Federal Government Efforts to Reduce Tobacco Use Over the last 50 years, the federal government has: Documented the lethal and addictive nature of tobacco products Supported state and community tobacco control efforts Required cigarette and smokeless tobacco products to carry warning labels Banned certain tobacco advertisements from television and radio Banned smoking from air travel Worked to educate the public about the lethal nature of secondhand smoke Supported education and research initiatives to prevent tobacco use and facilitate quitting

20 5 New Federal Laws with Tobacco Control Requirements American Recovery and Reinvestment Act Children s Health Insurance Program Reauthorization Act Family Smoking Prevention and Tobacco Control Act Prevent All Cigarette Trafficking Act The Patient Protection and Affordable Care Act

21 The American Recovery and Reinvestment Act Invested $200 million to support local, state, and national tobacco prevention and control efforts, thus mitigating decreases in state tobacco control budgets.

22 Children s Health Insurance Program Reauthorization Act The Act included an unprecedented 62-cent increase in the federal excise tax on cigarettes to $1.01 per pack. For every 10% increase in the price of tobacco products, consumption falls by approximately 4% overall, with a greater reduction among youth.

23 Family Smoking Prevention and Tobacco Control Act This law granted the Food and Drug Administration the authority to comprehensively regulate thousands of tobacco products for the first time in history. It facilitated the creation of the Center for Tobacco Products to regulate the manufacture, distribution, and marketing of tobacco products to protect public health.

24 Tobacco Control Act This law requires cigarette packages to have larger and bolder health warnings, including graphic images. Mandates tobacco companies to disclose harmful constituents in their products. Prohibits false or misleading labeling and advertising for tobacco products. Requires the tobacco industry to submit an application to the CTP for new products.

25 Tobacco Control Act (cont d.) New health warning labels will convey the harms of tobacco. The new warning photographs on cigarette packs hold the promise of stimulating even further attempts by smokers to quit, if the recent legal ruling suppressing their use can be overturned.

26 Importance of Monitoring the Effectiveness of Warning Labels & Visuals If the FDA is allowed to go forward with the proposed labels and visual warnings, close monitoring of their effectiveness will be needed. Impact of a powerfully reinforcing psychoactive substance. The dangers of desensitization and decreased response could occur if the images are seen as so extreme as to become cool. 26

27 Prevent All Cigarette Trafficking Act The law reduces the illegal sale and transport of cigarettes and other tobacco products. It will reduce and prevent smoking by blocking access to underpriced and untaxed cigarettes and smokeless tobacco products. It will help curtail online and mail order sales to underage youth by requiring sellers to verify a customer s age prior to sale by checking databases.

28 The Affordable Care Act As part of its emphasis on prevention and health promotion, the law: Requires private insurance plans to cover tobacco cessation treatments, including medications that help people quit smoking Expands smoking cessation coverage for pregnant women who receive Medicaid Provides Medicare beneficiaries with an annual wellness visit that includes referrals for tobacco cessation services

29 HHS Strategic Action Plan for Tobacco Control Ending the Tobacco Epidemic: A Tobacco Control Strategic Action Plan for the U.S. Department of Health and Human Services, November The Strategic Action Plan prescribes proven, practical, achievable actions that can be implemented at the federal, state, and community levels.

30 Four Tobacco-Related Objectives The Strategic Action Plan charts a framework designed to achieve four tobacco-related objectives of Healthy People 2020: Reduce tobacco use by adults and adolescents Reduce the initiation of tobacco use among children, adolescents, and young adults Increase smoking cessation success by adult smokers Reduce the proportion of nonsmokers exposed to secondhand smoke

31 Source: Ending the Tobacco Epidemic: Progress toward a Healthier Nation, August Barriers to Progress The tobacco industry continues to aggressively promote tobacco use and fuel addiction among consumers. Cigarette manufacturers spend $9.94 billion each year, or $27million each day, on advertising and promotions to attract new youthful users, retain current users, increase consumption, and generate favorable attitudes toward tobacco use.

32 Summary of Barriers to Providing Smoking Cessation in Substance Abuse Treatment Settings Resource Limitations Beliefs Other Factors Source Lack of staff knowledge or training Lack of staff time Perceived risk to sobriety Other addiction is more important Staff are smokers Staff Surveys Bobo & Gilchrist (1983) Bobo et al. (1995) Hahn et al. (1999) Gill & Bennett (2000) Olsen et al. (2005) Fuller et al. (2007) Director Surveys Knapp et al. (1993) Willenbring et al. (2004) McCool et al. (2005) Richter (2006) Director & Staff Surveys Walsh et al. (2005b) Source: Guydish, J., Passalacqua, E., Tajima, B., & Turcotte Manser, S. (2007). Staff smoking and other barriers to nicotine dependence intervention in addiction treatment settings: A review. Journal of Psychoactive Drugs, 39(4),

33 SAMHSA Tobacco Initiatives SAMHSA s Synar Program Works to Reduce Youth Access to Tobacco As a condition of receipt of their full Substance Abuse Prevention and Treatment Block Grant awards, the Synar amendment requires the 50 states, DC, and 8 U.S. territories to enact and enforce state laws prohibiting tobacco sales to youth.

34 Synar s Impact According to the most recent Synar report, all states and the District of Columbia were found to be compliant with the Synar requirements for the 6 th year in Synar history. A total of 34 states reported a retailer violation rate below 10%, while 12 states reported a rate below 5% -- a sign that the Synar program is contributing significantly to prevention efforts. 34

35 SAMHSA Tobacco Initiatives (cont d.) 100 Pioneers for Smoking Cessation Campaign SAMHSA collaborated with the Smoking Cessation Leadership Center (Univ. California, San Francisco) to implement the 100 Pioneers project in Through a competitive process, 100 of SAMHSA s grantees were provided $1,000 incentive awards to address Nicotine addiction and create smoke-free environments in Behavioral health settings. In 2010, 25 of the original Pioneers Were awarded an additional $2,000 stipend to expand their efforts. 35

36 100 Pioneers Progress Report The 100 Pioneers progress report documents the measurable results to date of the State Leadership Academies that were conducted in Arizona, Arkansas, Maryland, New York, North Carolina, Oklahoma, and Texas. These results include: 100% of states reported concrete, measurable improvements since the Leadership Academy summit 86% or 6 out of 7 states, reported increased quit attempts by behavioral health clients 86% or 6 out of 7 states cited strengthened tobacco-free policies 36

37 SAMHSA Tobacco Initiatives (cont d) Leadership Academies for Wellness and Smoking Cessation SAMHSA expanded the Pioneers project during the past two years ( ) by selecting 7 states (Arizona, Arkansas, Maryland, New York, North Carolina, Oklahoma, Texas) to establish leadership academies. The goal is to reduce tobacco use by individuals with mental health and substance use disorders. 37

38 SAMHSA Tobacco Initiatives (cont d) Tobacco Cessation in Opioid Treatment Programs In 2011, the Center for Substance Abuse Treatment funded a new contract designed to provide a comprehensive approach to addressing tobacco use among opioid-dependent individuals in opioid treatment programs. A toolkit will be developed with educational and clinical resources for OTP staff, patients, family, and caregivers on evidence based practices in tobacco dependence treatment. The project will provide a model for the integration of tobacco cessation services into behavioral health programs seeking to enhance wellness services in the areas of prevention, drug treatment, and physical health, thereby enhancing recovery. 38

39 IAA Between SAMHSA & FDA SAMHSA and FDA s Center for Tobacco Products have entered into an interagency agreement focusing on tobacco prevention and cessation messaging. The activity is targeted specifically at current illicit drug users and those suffering from a mental illness. Target populations include youth, LBGT populations, racial and ethnic minorities, and persons with cooccurring disorders. 39

40 SAMHSA Tobacco Initiatives (cont d) SAMHSA/HRSA Center for Integrated Health Solutions is developing resources to expand the use of tobacco cessation activities among SAMHSA s Primary and Behavioral Health Care Integration grantees. Screening, Brief Intervention and Referral to Treatment (SBIRT) SAMHSA has integrated screening and intervention for tobacco use among their SBIRT grantees. TIP 42: Substance Abuse Treatment for Persons with Co-occurring Disorders Includes a section on nicotine dependence 40

41 Thank you. 41