The importance of smoking cessation in improving the physical health of people with mental disorder: The evidence

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1 Collaboration for Leadership in Applied Health Research and Care South London (CLAHRC South London) The importance of smoking cessation in improving the physical health of people with mental disorder: The evidence Debbie Robson, RMN, PhD Senior Post Doc Researcher in Tobacco Addiction, Addictions Dept, IoPPN, KCL

2 Overview Impact of smoking and stopping smoking health and wellbeing Smoking cessation interventions in people with mental disorder

Physical health and SMI In South London, people with a serious mental illness die an average of 15-20 years earlier

discrimination (Thornicroft, 2013, Rethink, 2013) The most common causes of death are cardiovascular & respiratory

3 Physical health and SMI In South London, people with a serious mental illness die an average of years earlier than those without, from preventable conditions At best a failure to act on evidence; at worst a form of lethal discrimination (Thornicroft, 2013, Rethink, 2013) The most common causes of death are cardiovascular & respiratory diseases Multiple and complex causes of health inequalities Biggest risk factors are smoking, obesity, lack of exercise & alcohol use

Smoking and mental health Depression & Anxiety 2 General population 1 18.5% 32% Psychosis 3 60% Substance use 4 88% 1 in 2 smokers die prematurely (at least 10 years) 1.

4 Smoking and mental health Depression & Anxiety 2 General population % 32% Psychosis 3 60% Substance use 4 88% 1 in 2 smokers die prematurely (at least 10 years) McManus et al (2010) NCSR. 3. Wu C-Y et al. (2013). PLoS ONE 8(9): e Cookson C, et al (2014) BMC Health Services Research 2014, 14:304

What s in a cigarette? Dried tobacco leaves Fillers which include other parts of the tobacco plant such as the stem to give it bulk Additives e.g. ammonia to improve the transportation of nicotine Flavourings e.

5 What s in a cigarette? Dried tobacco leaves Fillers which include other parts of the tobacco plant such as the stem to give it bulk Additives e.g. ammonia to improve the transportation of nicotine Flavourings e.g sugars, cocoa and fruit extracts to make it taste more palatable Humectants, preservatives, pesticides - so that the tobacco stays moist and doesn t rot What s in tobacco smoke? 4000 chemicals, 69 of which cause cancer

6 Separate the nicotine from the smoke Smokers smoke for the nicotine, but die from the tar Professor Mike Russell, Maudsley Smokers Clinic, 1979

7 Impact of smoking on mental health, physical health and mortality

8 Approx 50% of smokers die prematurely lose 10 years Approx 1.6m hospital admissions in 2012/3 Smoking kills more people each year than the following preventable causes of death combined (Ash, 2013) Smoking 79,100 Obesity 34,100 Alcohol 6,669 Road traffic accidents 1,850 Illegal drugs 1,605 HIV/Aids 504

9 Impact on physical health

Smoking related death & disease CARDIOVASCULAR DISEASE Third of CVD deaths are caused by smoking Smoking damages the lining of your arteries, leading to a build up of fatty material (atheroma) and a

10 Smoking related death & disease CARDIOVASCULAR DISEASE Third of CVD deaths are caused by smoking Smoking damages the lining of your arteries, leading to a build up of fatty material (atheroma) and a reduced space for blood to pass through. The carbon monoxide in cigarette smoke reduces the amount of oxygen that the blood can carry to your heart and body. RESPIRATORY DISEASE 80-90% of all deaths from COPD are due to smoking People with SMI have an increased risk of dying from a respiratory disease - 10 times higher than the general population. Also more likely to suffer from asthma, chronic bronchitis and emphysema. Respiratory health is poor even in first episode patients

11 Smoking related death & disease Tobacco is the single biggest avoidable cause of cancer in the world. causes one in five cancer cases causes over a quarter of cancer deaths in the UK

$mineral density Falls & fractures [risk of fracture$ is increased by about 25%] Gum disease [the gums and

12 Smoking related death & disease Osteoporosis Low bone mineral density Falls & fractures [risk of fracture is increased by about 25%] Gum disease [the gums and bone recede] Lost teeth Increased risk of oral cancers

13 Smoking related death & disease Increased risk of infertility impotence pre term birth spontaneous abortion

14 Smoking: How does it impede mental health recovery? Smoking contributes to poor mental health (more severe symptoms of psychosis, higher rates of depression, longer time in hospital) Lower plasma levels of clozapine and olanzapine (up to 50%) - higher doses of medication Poverty (clients spent approx a third of their income on cigarettes) Exploitation & stigma (begging for cigarettes, picking up butts)

Smoking and suicide Smoking is associated with suicide Possible mechanisms 1? smokers have pre-existing conditions that increase their risk for suicide 2?

15 Smoking and suicide Smoking is associated with suicide Possible mechanisms 1? smokers have pre-existing conditions that increase their risk for suicide 2? smoking causes painful and debilitating conditions that might lead to suicide 3? smoking decreases serotonin and monoamine oxidase levels Hughes (2008 ) Drug Alcohol Depend. 98(3)

16 Drug interactions

Drugs metabolised by CYP450 1A2 Clozapine Olanzapine Haloperidol Perphenazine Fluphenazine Amitriptyline Imipramine Mirtazipine Duloxetine Caffeine Smoking when taking these meds speeds up their

17 Drugs metabolised by CYP450 1A2 Clozapine Olanzapine Haloperidol Perphenazine Fluphenazine Amitriptyline Imipramine Mirtazipine Duloxetine Caffeine Smoking when taking these meds speeds up their metabolism.this affects response to the medication make the drug ineffective because it has not been in the body long enough to have an effect Tobacco smoke (PHC from tar not nicotine) may decrease plasma levels, therefore need higher doses of the above drugs

CYP450 1A2 Stopping/restricting smoking Clozapine Olanzapine Haloperidol Perphenazine Fluphenazine Amitriptyline Imipramine Mirtazipine

18 CYP450 1A2 Stopping/restricting smoking Clozapine Olanzapine Haloperidol Perphenazine Fluphenazine Amitriptyline Imipramine Mirtazipine Duoxetine Caffeine Stopping/restricting tobacco smoke (tar not nicotine) may increase plasma levels, therefore need to monitor and may have to reduce dose

19 Antipsychotics (Taylor et al, 2012) DRUG EFFECT ON SMOKING ACTION TO BE TAKEN ON STOPPING SMOKING Chlorpromazine Plasma levels reduced. Varied estimates of exact effect Monitor closely, consider dose reduction Haloperidol Reduces plasma levels by around 20% Reduce dose by around 10% and continue to monitor Fluphenazine Reduces plasma levels by up to 50% On stopping, reduce dose by 25%. Monitor for up to 8 weeks. ACTION TO BE TAKEN ON (RE)STARTING SMOKING Monitor closely, consider restarting previous dose (when patient was a smoker) On restarting, increase dose to previous level. On restarting, increase dose to previous level. Zuclopenthixol Reduces plasma levels by up to 50% Take plasma level before stopping. On stopping, reduce dose by 25%. After 1 week, repeat plasma level. consider further reductions Clozapine Reduces plasma levels by up to 50%. May be a greater reduction in people taking Valproate Take plasma level before stopping. On stopping, reduce dose gradually (over a week) by 25%. Repeat plasma level 1 week after stopping. Continue to review dose Olanzapine Reduces plasma levels by up to 50% Take plasma level before stopping. On stopping, reduce dose by 25%. Take plasma level before resuming smoking (anticipate this may happen soon after discharge). Increase dose to previous dose (when patient was a smoker) Take plasma level before resuming smoking (anticipate this may happen soon after discharge). Increase dose to previous dose (when patient was a smoker) Take plasma level before resuming smoking (anticipate this may happen soon after discharge). Increase dose to previous dose (when patient was a smoker)

20 Impact of stopping smoking on health

21 Quitting: health benefits Circulation improves, walking becomes easier Lung function increases up to 30% Excess risk of CHD decreases to half that of a continuing smoker Lung cancer death rate drops to half that of a continuing smoker Risk of cancer of mouth, throat, esophagus, bladder, kidney, pancreas decrease time since quit date 2 weeks to 3 months 1 to 9 months 1 year 10 years 5 years after 15 years Lung cilia regain normal function Ability to clear lungs of mucus increases Coughing, fatigue, shortness of breath decrease Risk of stroke is reduced to that of people who have never smoked Risk of CHD is similar to that of people who have never smoked

22 Stopping smoking is associated with improved mood, anxiety and wellbeing. This effect is equal or larger to that of antidepressant/anxiolytic treatment for mood disorders

23 Smoking cessation interventions in people with mental disorder

24 Gold standard treatment Medication (Nicotine Replacement Therapy or bupropion or varenicline), combined with intensive behavioural support (6-12 weeks) delivered by an NHS Stop Smoking Service Product Trials, n Sample size, n Quit rate at 6+ months NRT (any product) ,265 17% Bupropion 36 10,940 19% Varenicline % Total ,648 Any of these drugs double the chance of quitting and maintaining abstinence compared to placebo Cochrane reviews

25 What works? General Population Smokers (Cochrane reviews) Product Trials, n Sample size, n Quit rate at 6+ months NRT (any product) ,265 17% Bupropion 36 10,940 19% Varenicline % Total ,648 Any of these drugs double the chance of quitting and maintaining abstinence compared to placebo Schizophrenia Smokers Product RCTs, n Sample size n Quit rate at 6+ months NRT (any product) & group/individual support % Bupropion & group support % Varenicline & group support %-60% Total

26 The role of pharmacotherapy Reduce the strength, duration or frequency of urges to smoke Reduce unpleasant withdrawal symptoms Reduce the pharmacological reward from smoking

27 Nicotine Nicotine in a cigarette: 7-10mg Smoking delivers about 1-3 mg to the smoker (about 0.7 ug/puff) Technique of smoker can increase nicotine (time smoke is in lungs, rapid puffing) It stimulates the central nervous system, increasing the heart rate & blood pressure, leaving the heart to work harder for more oxygen. Withdrawal symptoms Dizziness, light headed Sleep disturbance Irritability, restlessness Difficulty in concentrating Depressed mood Constipation Mouth ulcers Urge to smoke Increased appetite/weight gain Average duration < 2 days < 2 weeks < 4 weeks < 4 weeks < 4 weeks < 4 weeks < 4 weeks > 10 weeks > 10 weeks Half-life of nicotine is about 2 hours Most symptoms peak hr after quitting and subside within 2 4 weeks.

28 Nicotine The jagged line represents venous plasma concentrations of nicotine as a cigarette is smoked every 40 minutes from 8 am to 9 pm. The upper solid line indicates the threshold concentration for nicotine to produce pleasure or arousal. The lower solid line indicates the concentrations at which symptoms of abstinence (i.e., withdrawal symptoms) from nicotine occur. The shaded area represents the zone of nicotine concentrations (neutral zone) in which the smoker is comfortable without experiencing either pleasure/arousal or abstinence symptoms.

29 Licenced stop smoking medicines Nicotine inhaler Nicotine gum Nicotine nasal spray Voke nicotine inhaler Nicotine mouth spray Nicotine patch Bupropion (Zyban) Varenicline (Champix) Electronic cigarettes

Nicotine Replacement Therapy (NRT). NRT is more effective if you use two types toge

It is to be used for about 8-12 weeks (absorbed through the cheeks and lips/skin/nasal)

The long-lasting action means they can be worn around the clock.

You normally start with one lozenge/pieces of gum every hour Inhalers can help if you miss

Nasal and mouth sprays deliver nicotine quicker than other NRT products.

30 Nicotine Replacement Therapy (NRT). NRT is more effective if you use two types together e.g. patch + gum, patch + inhalator. It is to be used for about 8-12 weeks (absorbed through the cheeks and lips/skin/nasal) Nicotine patches deliver a regular dose of nicotine over 16 or 24 hours. The long-lasting action means they can be worn around the clock. Lozenges and chewing gum release nicotine as they absorbed through the cheeks. You normally start with one lozenge/pieces of gum every hour Inhalers can help if you miss the physical action of smoking. You can have up to 6 cartridges a day. Nasal and mouth sprays deliver nicotine quicker than other NRT products. You can have up to 64 sprays a day (1-2 sprays an hour) Tablets that dissolve under your tongue can be more discreet than lozenges. You normally start with one to two tablets per hour up to a maximum of 40 per day. Mouth strips - dissolve on the tongue you can have 15 a day

31 Nicotine Replacement Therapy Licenced for smokers over the age of 12, devices to deliver nicotine into the bloodstream to reduce motivation to smoke by reducing cravings and withdrawal symptoms reducing the rewarding effect of smoking options patch gum, inhaler, microtab, lozenge,strips nasal spray, mouth spray slowest absorption intermediate absorption fastest absorption Sudden cravings brought on by emotional/environmental cues Minimum of 8 weeks

32 Optimising effectiveness of NRT Barriers Suboptimal dosing Incorrect use and poor technique Not used for long enough Beliefs about nicotine & NRT Concerns about smoking and using NRT at the same time Fears of overdose Education for staff and patients Combining patches with maximum amount of oral NRT Smokers need to be able to titrate their own nicotine, just as they do from cigarettes Consider using double patches Repeated messages about correct technique (needs to be absorbed through buccal mucosa, not swallowed) Stay on NRT if relapse to smoking Increase the length of treatment NRT is licensed & recommended to be used during periods of temporary abstinence and whilst cutting down

33 Varenicline (Champix ) Nicotinic acetylcholine partial agonist targeting α4β2 receptor subtype, designed to reduce motivation to smoke by reducing cravings and withdrawal symptoms reducing the rewarding effect of smoking options Titrate up to 2mg per day 1mg per day, if side effects 12 weeks 2mg per day, maintenance therapy 1mg per day, if side effects + 12 weeks Cahill K et al (2007). Cochrane Database Syst Rev: CD

34 Bupropion (Zyban) Atypical antidepressant which acts on dopamine and noradrenaline pathways and possibly as a nicotinic antagonist, designed to reduce motivation to smoke by reducing cravings and withdrawal symptoms reducing the rewarding effect of smoking Started a week prior to quitting, titrated up to 300mg per day 150mg per day, if side effects Used for at least 8 weeks Hughes J et al (2004). Cochrane Database Syst Rev: CD Zyban (Summary of Product Characteristics) GlaxoSmithKline, Uxbridge, UK.

35 Specialist Stop Smoking Services give the best results NHS support and medication Medication on prescription NRT over-the-counter Significantly better than no help No medication or support (reference) Odds ratio (relative to no help) Data from R West) based on smokers who tried to stop in the past year who report still not smoking at the survey adjusting for other predictors of success (age, dependence, time since quit attempt, social grade, recent prior quit attempts, abrupt vs gradual cessation): N=7,939

36 Drop In Clinic Acute In-Patient Unit Robson et al (2012) of Clinical Nursing

37 Evaluation Drop In service Smoking Cessation Specialist Employed by PCT 3 months Level 2 Training Drop In service 1 Mental Health Nurse 1 OT Technician 1 Health Care Assistant Staffed on a rota basis 3 months Robson et al (2012) Journal of Clinical Nursing

38 Service User Outcomes In patient unit consisted of 2 acute wards 1 PICU 212 patients were admitted in 6 months Smoking status not routinely recorded 46 patients set a quit date Robson et al (2012) Journal of Clinical Nursing

39 Quit rate at 4 weeks 28% (13/46) Robson et al (2012) Journal of Clinical Nursing

40 The development and evaluation of a smoking cessation intervention for people with schizophrenia Robson (2013) PhD Thesis, KCL

Interpersonal skills ASSESSMENT Smoking history typical day severity of dependence Physical health pxd meds mental health relapse signature finances PHASE 1 PREPARING TO CUT DOWN : 3 weekly sessions

oral NRT Mastery of NRT and personal coping plan STOPPING: 5 weekly sessions QUIT DAY (approx session 8) Supply of combination NRT Enhancing adherence to NRT Monitoring personal coping plan and

41 Interpersonal skills ASSESSMENT Smoking history typical day severity of dependence Physical health pxd meds mental health relapse signature finances PHASE 1 PREPARING TO CUT DOWN : 3 weekly sessions Exploring ambivalence Looking back Exchanging information Personal coping plan problem solving Lung age feedback PHASE 2: PHASE 3 CUTTING DOWN: 4 weekly sessions structured reduction plan Supply of oral NRT Mastery of NRT and personal coping plan STOPPING: 5 weekly sessions QUIT DAY (approx session 8) Supply of combination NRT Enhancing adherence to NRT Monitoring personal coping plan and mental health Process skills PHASE 4 STAYING SMOKE FREE: 3 alternate weekly sessions Supply of combination NRT Reviewing personal coping plan & devising a staying smokefree success plan Health behaviour change techniques based on psychoeducation,cbt, & MI

Sample & Setting 30 community patients living in Lambeth, South London, UK Diagnosis of schizophrenia Clinically stable for at least 1 month 19 men, 11

42 Sample & Setting 30 community patients living in Lambeth, South London, UK Diagnosis of schizophrenia Clinically stable for at least 1 month 19 men, 11 women: average 40 years, smoked for 20 years Smoked 30 cigarettes a day (range 10-70) 50% had a co morbid physical health problem (CVD, cancer, diabetes, COPD)

43 Feasibility & Acceptability 38 mins Mean duration of session 26 (86.7%) Attended 8 > sessions 8.08 hours Mean duration of intervention 19 (63.3% ) Attended 15 sessions

44 Number of smokers Potential effect: continuous abstinence Local 4 week quit rates 31% in local gen pop Lambeth, UK / % 10/ % 8/ % 5 0 baseline 1 week 4 weeks 6 months Post quit date

45 Smokefree hospitals as an intervention

46 Nov 2013 NICE Guidelines smoking cessation in secondary care

47 Total smoke free mental health settings are associated with Smoking cessation in patients and staff [acute: with treatment and follow up up to 20%, 1 longer stay up to 58% 2 ] Increased likelihood of making a subsequent quit attempt following discharge 3 Increased expectancy of success and self efficacy 4 Positive wellbeing 2 Changes to smoking culture 4 1. Prochaska et al (2014) Am J Public Health Hehir et al (2012) Drug & Alcohol Review, 31(5) Prochaska et al (2006)Am J Addict 15, Ashton et al (2010) Aust N Z J Psych. 44,

48 Smoking related violence Oct to Dec Total violent incidents Oct Dec 2013 = 226 Oct Dec 2014 = Oct to Dec Pre Post 2 1 0

49 % of Patients 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Impact of smoking on treatment (inpatient setting) Smoker, No NRT Smoker, NRT NonSmoker Inpatient smokers twice as likely to leave AMA, if withdrawal not treated with nicotine replacement 22% 17% 10% 8% 10% 8% 83% 70% 69% Discharge AMA Placed in Seclusion Benzo Prescription Prochaska, Gill, & Hall. (2004) Psychiatric Services

I hate walking to the garage at 2 in the morning.that s not good is it?.i m going to make myself thoroughly ill.

50 Staff attitudes (Ratschen et al, 2009) 459 mental health workers Patient attitudes (Robson, 2013) 30 patients with schizophrenia receiving a stop smoking intervention Smoking is the least of their problems.dealing with their mental illness is the priority It stinks.revolting. I hate walking to the garage at 2 in the morning.that s not good is it?.i m going to make myself thoroughly ill. I m crippling myself It s a burden on the family, they are going without essentials. It s a choice between buying bread or fags. So the family don t have breakfast some days

51 Staff attitudes (Ratschen et al, 2008;2009) 2009) Patient attitudes (Robson, 2013) 459 mental health workers 30 patients with schizophrenia receiving a stop smoking intervention It s the only thing they have control over it s unethical to undermine it I feel more in control of myself and my life, I m not sort of stuck, tied to these blessed cigarettes quite so much and I do feel better for it

Staff attitudes (Ratschen et al, 2009) 459 mental health workers Patient attitudes (Robson, 2013) 30 patients with schizophrenia receiving a stop smoking intervention Smoking is the only

52 Staff attitudes (Ratschen et al, 2009) 459 mental health workers Patient attitudes (Robson, 2013) 30 patients with schizophrenia receiving a stop smoking intervention Smoking is the only pleasure they have got in life and I don t want to be the one taking it away I feel so rich these days, the richest I have ever been For the first time in my life I feel I can do anything

53 Collaboration for Leadership in Applied Health Research and Care South London (CLAHRC South London) Thank you Debbie Robson, RMN, PhD Senior Post Doc Researcher in Tobacco Addiction, Addictions Dept, IoPPN, KCL

The importance of smoking cessation in improving the physical health of people with mental disorder: The evidence

Collaboration for Leadership in Applied Health Research and Care South London (CLAHRC South London) The importance of smoking cessation in improving the physical health of people with mental disorder: