Welcome and Webinar Logistics

Transcription

1 Welcome and Webinar Logistics We recommend calling in on your telephone Remember to enter your Audio PIN so we can unmute your line when you have a question Audio PIN: Will be displayed after you login This button should be clicked if you re calling in by telephone. Here s your audio PIN

2 How to Ask a Question Prefer to write? Type into the question box and click send. On the phone? Raise your hand and we will open up your lines for you to ask your question to the group.

3 Making the Case for Smoking Cessation Chad Morris, PhD Behavioral Health & Wellness Program Tobacco Free Environments Webinar Friday, June 6, 2014

4 The Health Consequences of Smoking: 50 Years of Progress A Report of the Surgeon General

5 Trends in Adult Smoking Males 19.3% of adults are current smokers Females Graph provided by the Centers for Disease Control and Prevention Current Population Survey; NHIS. Estimates since 1992 include some-day smoking.

6 Prevalence Among Older Adults In the US, people aged 65 years and older have the lowest prevalence of current smoking (8.3%) among all adults. This is largely due to the premature death of older smokers from tobacco-related disease and cessation among those already experiencing the health effects of tobacco.

7 Behavioral Causes of Death in U.S. 500, , , , , , , , ,000 50,000 0 * Persons with Behavioral Health Conditions 8,300 25,700 31,700 16,300 33,700 43,000 38, , ,000 *

8 Tobacco and Behavioral Health Populations Persons with behavioral health conditions: Are nicotine dependent at rates 2-3 times higher Represent over 44% of the U.S. tobacco market Consume over 34% of all cigarettes smoked

9 Tobacco Use by Diagnosis Schizophrenia 62-90% Bipolar disorder 51-70% Major depression 36-80% Anxiety disorders 32-60% Post-traumatic stress disorder 45-60% Attention deficit/ hyperactivity disorder 38-42% Alcohol abuse 34-80% Other drug abuse 49-98%

10 Health Risks for Older Smokers 80% of people aged 65 and older have at least one chronic disease condition. Many of these chronic disease conditions are caused or exacerbated by smoking. Smoking reduces bone density and increases risk for hip fractures. Smoking is a risk factor for cognitive decline and dementia.

11 Common Concerns They will lose their sobriety if they also try to quit smoking. It is too late. They don t want to. It isn t relevant They need to smoke to cope with stress They can t quit I ve always heard smoking helps symptoms. I don t want to make their symptoms worse.

12 Smoke breaks are a time when I build relationships with clients. The issues we face are unique. Common Concerns How are we going to fund this? This is one of their last personal freedoms. I don t have the training necessary. If we go tobaccofree, behavioral problems will increase. Why spend time on this when there are more important psychiatric, substance abuse, and medical issues?

13 It is never too late to quit. Quitting has benefits at all ages. If you quit smoking, you can not only immediately improve your health, but also add years to your life. Smoking cessation at age 65 leads to an increase in life expectancy of 1.4 to 2.0 years for men and 2.7 to 3.7 years for women

14 The Stress and Smoking Connection The majority recognize smoking is physically unhealthy But mistakenly believe it has positive psychological functions In particular- stress relief Smoking is used as an indirect coping strategy And perceived stress reduction is often relief of withdrawal symptoms

15 Nicotine Withdrawal Effects Irritability/ Frustration/ Anger Anxiety Difficulty Concentrating Restlessness/ Impatience Depressed Mood Insomnia Increased Appetite Most symptoms: Appear within the first 1 2 days Peak within the first week Decrease within 2 4 weeks

16 Schizophrenia Decreased α-7 nicotinic receptors Nicotine activates nachr Partially normalizes sensory processing deficits Smoking may improve negative symptoms & cognitive functioning attention orientation

17 ANTIPSYCHOTICS ANTIDEPRESSANTS MOOD STABLIZERS ANXIOLYTICS OTHERS Medications Known or Suspected To Have Their Levels Affected by Smoking and Smoking Cessation Chlorpromazine (Thorazine) Clozapine (Clozaril) Fluphenazine (Permitil) Haloperidol (Haldol) Mesoridazine (Serentil) Amitriptyline (Elavil) Clomipramine (Anafranil) Desipramine (Norpramin) Doxepin (Sinequan) Duloxetine (Cymbalta) Carbamazepine (Tegretol) Alprazolam (Xanax) Diazepam (Valium) Acetaminophen Caffeine Heparin Insulin Rasagiline (Azilect) Olanzapine (Zyprexa) Thiothixene (Navane) Trifluoperazine (Stelazine) Ziprasidone (Geodon) Fluvoxamine (Luvox) Imipramine (Tofranil) Mirtazapine (Remeron) Nortriptyline (Pamelor) Trazodone (Desyrel) Lorazepam (Ativan) Oxazepam (Serax) Riluzole (Rilutek) Ropinirole (Requip) Tacrine Warfarin

18 Cessation Concurrent with Psychiatric Treatment Smoking cessation has no negative impact on psychiatric symptoms and smoking cessation generally leads to better mental health and overall functioning. Baker et al., 2006; Lawn & Pols, 2005; Morris et al., 2011; Prochaska et al., 2008

19 Psychiatric Symptoms Are Not Exacerbated by Smoking Cessation Smoking cessation is associated with: depression, anxiety, and stress positive mood and quality of life compared with continuing to smoke The effect size seems as large for those with psychiatric disorders as those without The effect sizes are equal or larger than those of antidepressant treatment for mood and anxiety disorders Taylor et al, 2014

20 Tobacco Use Affects Treatment & Recovery from Addiction Addressing tobacco dependence during treatment for other substances is associated with a 25% increase in long-term abstinence rates from alcohol and other substances Prochaska et al., 2004

21 Quitting: It Can Be Done Persons with behavioral health conditions: Are able to quit using 75% want to quit using 65% tried to quit in the last 12-months

22 Why Community Treatment Settings? Expertise in behavioral change Therapeutic alliances Co-occurring treatment Access to high risk populations Patient-directed Complements other prevention and wellness activity Continuity of care Performance measurement

23 Integration is the New Norm Mental health and addictions Across healthcare sectors Integrated care & health homes Public health Quitlines Community integration Chronic care Diagnoses/ codes EHRs & performance measurement

24 Tobacco Cessation Strategies

25 Tobacco Dependence Has Two Parts Tobacco dependence is a 2-part problem Physical The addiction to nicotine Treatment Behavior The habit of using tobacco Treatment Medications for cessation Behavior change program Treatment should address both the addiction and the habit. Courtesy of the University of California, San Francisco

26 Behavior Change Interventions Screening, Assessment, Intervention, & Referral Cognitive-Behavioral Therapy Physician Advice Individual counseling > 4 sessions > 10 minutes Psycho-educational groups Peer support Age-tailored self-help materials Referral to quitlines

27 Tobacco Cessation Interventions: The 5 A s Model ASK ADVISE ASSESS ASSIST ARRANGE about tobacco USE tobacco users to QUIT READINESS to quit with the QUIT ATTEMPT FOLLOW-UP care

28 Tobacco Cessation Interventions: 5 A s ASK all individuals about tobacco use Do you, or does anyone in your household, use any type of tobacco? How many times have you tried to quit? Explore tobacco use history

29 Tobacco Cessation Interventions: 5 A s ADVISE people who use tobacco to quit Provide a clear, personalized and non-judgmental message about the health benefits of quitting tobacco What would motivate the person to quit?

30 Advice Can Improve Chances of Quitting Estimated abstinence at 5+ months No clinician Compared to people who smoke who do not get help from a clinician, those who get help are times as likely to successfully quit for 5 or more months. Self-help material 1.7 Nonphysician clinician Type of Clinician 2.2 Physician clinician

31 Tobacco Cessation Interventions: 5 A s ASSESS readiness to quit How do you feel about your smoking? Have you considered quitting? Explore barriers to quitting Assess nicotine dependence How many cigarettes do you smoke a day? How soon after you wake do you have your first cigarette?

32 Tobacco Cessation Interventions: 5 A s ASSIST individuals interested in quitting Set a quit date or gradually cut down Discuss their concerns Encourage social support

33 Tobacco Cessation Interventions: 5 A s ARRANGE follow-up visits to track progress Encourage individuals to join the Tobacco Free group Discuss ways to remove barriers Congratulate successes Encourage individuals to talk with their providers

34 Quitlines

35 Brief & Intensive Counseling

36 Matching Patient Readiness Stage Definition Intervention Pre-contemplation Not considering changing Educate/Inform Contemplation Preparation Action Maintenance Thinking about making a change Actively considering changing in the immediate future or within the next month Making overt attempts to change Made changes for longer than six months Encourage/Motivate Assist with goal setting Provide support, assist as needed to overcome barriers Continued support, set new goals when ready 2015 Behavioral Health and Wellness Program, University of Colorado Anschutz Medical Campus

37 Creating Healthy Habits Cue Routine Reward Identify Cues Change the Reward Pathway Shape the Environment

38 Motivation Among Older Adults More likely to successfully quit when they try. Motivation often linked to a diagnosed chronic illness. Important to know that cessation increases effectiveness of medical treatment. More likely to quit due the death of a loved one.

39 DIMENSIONS: Tobacco Free & Well Body Program Training Materials Advanced Techniques Manual Group Facilitator Manual Electronic copies of materials

40 Role of the Tobacco Free Program Facilitators Raise awareness through center in-services, lunch and learns, and trainings Conduct individual motivational interventions Facilitate Tobacco Free groups Make referrals to other healthcare providers and community cessation services Create a positive social network

41 Motivational Intervention

42 Motivational Intervention Conduct semi-structured interview Work with individuals to increase their readiness for tobacco cessation Provide brief, personalized feedback about their carbon monoxide levels and the cost of smoking Encourage individuals to set concrete and manageable goals Discuss and list the supports they need to set a quit date and sustain their quit attempt

43 Tobacco Free Program

44 The Stethoscope of Smoking Cessation Non-invasive Visual motivational tool Myth busting Severity of dependence Likelihood of cravings

45 Common Elements of Counseling Treatment Component Recognize danger situations Develop coping skills Provide basic information Examples Negative affect and stress Being around other tobacco users Drinking alcohol Experiencing urges Smoking cues Learning to anticipate and avoid Learning cognitive strategies that will reduce negative moods Accomplishing lifestyle changes that reduce stress, improve quality of life, and reduce exposure to smoking cues Learning cognitive and behavioral activities (e.g., distracting attention; changing routines) Even a single puff may cause relapse Expected withdrawal symptoms The addictive nature of smoking PHS Clinical Guideline, 2008

46 Intra-Treatment Support Supportive Treatment Component Example Encourage the patient in the quit attempt Note that effective tobacco dependence treatments are now available Note that one-half of all people who have ever smoked have now quit Communicate belief in patient s ability to quit Communicate caring and concern Encourage the patient to talk about the quitting process Ask how patient feels about quitting Directly express concern and willingness to help as often as needed Ask about the patient s fears and ambivalence regarding quitting Ask about: Reasons the patient wants to quit Concerns or worries about quitting Success the patient has achieved Difficulties encountered while quitting PHS Clinical Guideline, 2008

47 Tobacco Free Group (or Individual Counseling) Session A: Creating a Plan Session B: Healthy Behaviors Session C: The Truth about Tobacco Session D: Changing Behaviors Session E: Coping with Cravings Session F: Maintaining Change *Groups are typically 90 minutes

48 Focus on Resiliency Older adults have specific strengths that can help them quit. They have learned life experience overcoming difficulties. May have more dedication toward attaining goals.

49 A Peer-to-Peer Model Peer Advocate/ Mentor An individual with lived experience who has received specialized training and supervision to work with others who have a similar history

50 Tobacco Dependence Has Two Parts Tobacco dependence is a 2-part problem Physical The addiction to nicotine Treatment Behavior The habit of using tobacco Treatment Medications for cessation Behavior change program Treatment should address both the addiction and the habit. Courtesy of the University of California, San Francisco

51 Tobacco Cessation Medications The only medications approved by the Food and Drug Administration (FDA) for tobacco cessation are: Nicotine gum Nicotine lozenge Nicotine patch Nicotine nasal spray Nicotine inhaler Bupropion SR tablets Varenicline tablets

52 Combination Therapy Use of two or more forms of tobacco cessation medications can improve cessation rates: PLUS OR OR OR PLUS PLUS OR Kozlowski et al., 2007; Bohadana et al., 2000; Piper et al., 2009

53 Medication Use Among Older Smokers More likely to mistrust medication use. More likely to believe medications are a replacement addiction. Often more wary of medication costs. * More education is warranted.

54 BHWP Toolkit

55 Integration Strategies

56 Integration into Standard Practice Assess tobacco as part of normal assessment & screening Add tobacco cessation to treatment plan

57 EHR Domains Richter et al. UKanQuit, University of Kansas Hospital Screening: ID smoking status Treatment: Offer counseling Treatment: Offer medications

58 Resources

59 Behavioral Health & Wellness Program Behavioral Health and Wellness Program BHWP_UCD