Importance of smoking cessation in improving the physical and mental health of people with mental illness

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1 Importance of smoking cessation in improving the physical and mental health of people with mental illness Dr Jonathan Campion Director of Public Mental Health and Consultant Psychiatrist South London and Maudsley NHS Fuondation Trust Director of Population Mental Health, UCLPartners Visiting Professor of Population Mental Health, UCL 1 Smoking Cessation in Mental Health London 23 th May 2014

2 2 Impact of smoking on physical health, mortality and mental health

3 3 Impact of smoking Largest cause of preventable death in England Responsible for 79,100 deaths and 459,900 hospital admissions In 2010/11 (HSCIC, 2012) Smokers die an average 10 years earlier than non-smokers (Doll et al, 2004) Smoking associated with increased risk of cardiovascular disease peripheral arterial disease (10-16 fold increased risk of amputation) chronic obstructive pulmonary disease type 2 diabetes (60% increased risk) cancer blindness Smoking - one of most important modifiable risk factors for both premature mortality and chronic disease

4 Impact of smoking in people with mental disorder Smoking - single largest contributor of year reduced life expectancy of people with mental disorder Depression: 11 years (men), 7 years (women) (Chang et al, 2011) Schizophrenia: 21.7 years (men), 17.5 years (women) (Brown et al, 2011) Alcohol use disorder: 10.8 years (women), 17.1 years men (Hayes et al, 2011) Opioid use disorders: 17.3 years (women), 9.0 years (men) (Hayes et al, 2011) Personality disorder: 18 years (Fok et al, 2012) 4

5 5 Impact related to higher smoking levels in people with mental disorder

6 Levels of smoking in people with mental disorder Compared to general population, people with mental disorder more likely to smoke smoke more heavily experience disproportionate levels of smoking associated harm 6

7 Smoking rates in adolescents with mental disorder (Green et al, 2005) 5% among year olds in the general population 30% among the 6% of year olds with conduct disorder 19% among the 4% of year olds with emotional disorder 15% among the 3.5% of year olds with attention deficit hyperactivity disorder 7

8 Smoking rates in adults with mental disorder Compared to 20% smoking rates in the adult population, smoking rates are higher for people with different mental disorders: Common mental disorder: 32% (McManus et al, 2010), 27% for those on antidepressants, 30% for those on anxiolytics (Szatkowski et al, 2013) Psychosis: 40% (McManus et al, 2009), 59% of people with first episode psychosis (Myles et al, 2012), 59% for those taking antipsychotics (Szatkowski et al, 2013) Drug dependence: 69% (McManus et al, 2009) Alcohol dependence: 46% Suicide attempt in past year: 57% Inpatient units: 70% of patients in mental health units smoke 50% are heavy smokers (Jochelson et al, 2006) 8

9 Population impact of smoking in people with mental disorder In England, 42% of adult tobacco consumption by those with mental disorder (McManus et al, 2010) 31% of adult tobacco consumption in England by people with common mental disorder (McManus et al, 2010) 43% of smokers in UK aged have either conduct or emotional disorders (Green et al, 2005) Similar proportion of tobacco related harm in people with mental disorder more than 40% of tobacco related deaths by people with mental disorder 9

10 Impact of smoking on risk of developing mental disorder Smoking during pregnancy associated with: 2-fold increased risk of conduct disorder in boys at age 3 (Hutchinson et al, 2010) 2-fold increased risk of antisocial behaviour and ADHD in older children (Button et al, 2007) Common mental disorder Smoking associated with increased risk of developing depression (RCP/RCPsych, 2013) and anxiety disorders (Cuijpers et al, 2007) Amount of tobacco smoked associated with number of depressive/anxiety symptoms (Farrell et al, 2001; Campion et al, 2008) Dementia: Smoking associated with (Anstey et al, 2007) 79% increased risk of Alzheimer s Disease 78% increased risk of Vascular dementia 10

11 11 Impact of smoking cessation on physical health and mental health

12 Benefits of smoking cessation Physical: Improved respiratory, vascular, reproductive, gastrointestinal and general health even within a few months of cessation (NCSCT, 2013) Mental Improved mental health/wellbeing, self-confidence, social interaction (RCP/RCPsych 2013) Reduced depressive and anxiety symptoms (RCP/RCPsych 2013) Impact on mood and anxiety disorders at least as large as antidepressant treatment (Taylor et al, 2014) Pharmacotherapy can minimise withdrawal symptoms which are relatively short lived 12

13 Benefits of smoking cessation Financial gains (NCSCT, 2013) and 25% reductions in financial stress (Siahpush et al, 2007) Dosage reduction of some medications (Taylor et al, 2012) up to 25% within 1st week after smoking cessation up to 50% four weeks after cessation Benefits of smoking cessation even greater for people with mental disorder given year lower life expectancy 13

14 14 Smoking cessation and reduction interventions

15 Effective smoking cessation/ reduction interventions Smokers with mental disorder - as motivated to stop as smokers without mental disorder (Siru et al, 2008) Different types of support increase rates of successful smoking cessation attempts in people with mental disorder People wanting to stop smoking should be offered a combination of pharmacotherapy and non-pharmacological approaches Higher cessation rates for people with mental disorder by more intensive and combined interventions - as for other people with higher levels of nicotine dependence 15

16 Effective smoking cessation/ reduction interventions Evidence based smoking cessation interventions are effective for people with mental disorder (NICE, 2013) Require additional monitoring for medication dose adjustment and potential deterioration in mental health (NICE, 2013) Evidence based interventions support reduction of tobacco use while people continue to smoke and double cessation rates (NICE, 2013) 16

17 Pharmacological interventions Different pharmacotherapies effective for smoking cessation in the general population Effective in people with mental disorder Greater levels of cessation/ reduction by: combined pharmacological interventions at higher doses together behavioural support 17

18 Nicotine Replacement Therapy Nicotine Replacement Therapy (NRT) effective (OR 1.84) (Cahill et al, 2013) Nasal spray most effective, then tablets/ lozenges, inhalers, patches, gum least effective (Stead et al, 2008) More effective in combination with a patch and faster acting form such as gum, inhalator and spray Combination NRT for people with mental disorder more effective and required for longer than 8-12 weeks (NICE, 2013) Unlicensed nicotine-containing products such as e-cigarettes likely to be less harmful than tobacco although people using such products should be encouraged to switch to licensed products (NICE, 2013) 18

19 Bupropion Other pharmacological interventions Effective (OR 1.82) (Cahill et al, 2013) Almost triples cessation rates at 6 months for those with schizophrenia with no reported serious adverse events (Tsoi et al, 2010) Nortriptyline - effective (OR 2.03) (Cahill et al, 2013) Cystine - effective (OR 3.98, ) (Cahill et al, 2013) Varenicline - effective (OR 2.88, ) (Cahill et al, 2013) 19 Some evidence supporting use in people with depression (RCP/RCPsych, 2013) Review did not support use in people with schizophrenia (NICE, 2013)

20 Comparing pharmacological interventions (Cahill et al, 2013) NRT and bupropion equally effective Varenicline more effective than bupropion or single forms of NRT Varenicline - equally as effective as combination NRT Addition of bupropion or nortriptyline does NOT increase effectiveness of NRT Combination of different forms of NRT and NRT/ bupropion reduces smoking consumption in people with mental disorder (RCP/RCPsych, 2013; NICE, 2013) 20

21 Non-pharmacological interventions Interventions likely to be effective for people with mental disorder Simple advice from doctors (Stead et al, 2008) Smoking cessation advice given by nurses (Rice et al, 2008) Multi-sessional intensive behavioural support (Stead et al, 2007) 21 more effective in groups than individual more effective than self-help or other less intensive interventions Telephone support (Stead et al, 2006) and multiple call-back counselling improves cessation rates (Stead et al, 2007) Some internet based interventions (Civljak et al, 2013) For smokers with mental disorder (NICE, 2013) Motivational interviewing increases referrals for smoking cessation Contingency payments with or without NRT/ bupropion reduce consumption in those with schizophrenia

22 Combined interventions Depression: Mood management strategies in combination with pharmacotherapy (van der Meer et al, 2013) Schizophrenia: Weak evidence for increased rates of cessation and reduction using combination high intensity behavioural therapy with NRT (NICE, 2013) Key message: Combination NRT should be offered to all smokers with mental disorder with the options of further interventions as required. 22

23 Population approaches Smoke-free policies and campaigns targeting people with mental disorder including in secondary care settings (NICE, 2013) Assessing compliance with tobacco legislation Addressing illicit tobacco 23

24 24 Prescribing considerations

25 Prescribing considerations Smoking increases metabolism of some medications (Taylor et al, 2012) some antidepressants (tricyclics and mirtazapine) some antipsychotics (clozapine, olanzapine and haloperidol) benzodiazepines opiates Results in significantly lower plasma levels which mean that larger doses are required for similar therapeutic effects 25

26 Prescribing considerations after cessation (Taylor et al, 2012) Following smoking cessation, doses of these medications need to be reduced within days to prevent toxicity: Clozapine and olanzapine: 25% dose reduction during 1st week of cessation and then weekly blood levels until levels stabilised Fluphenazine and some benzodiazepines: 25% dose reduction in 1st week Tricyclic antidepressants: 10-25% dose reduction in 1st week Further dose reductions may be required with continued cessation Original doses need to be reinstated if smoking resumed 26

27 Potential side effects of bupropion and varenicline Bupropion and varenicline are effective and well tolerated Recent Cochrane review found no excess neuropsychiatric or cardiac side effects of buprppion or varenciline (Cahill et al, 2013) Large prospective cohort study finding no increased risk of treated depression or suicidal behaviour (Thomas et al, 2013) However, reports of neuropsychiatric side effects for both bupropion and varenicline even in people without pre-existing mental disorder (MHRA, 2009) Therefore, care advised if prescribed for people with history of mental disorder due to relative lack of evidence in this group 27

28 Monitoring of mental state during cessation Need to keeping in mind benefits of smoking cessation to both mental and physical health Depressive symptoms may worsen in a minority of people following cessation (Hughes, 2007) Symptoms of schizophrenia do not appear to worsen Monitoring with bupropion and varenicline 28 Warn people of potential increased risk of adverse neuropsychiatric symptoms Monitor regularly particularly in the first 2-3 weeks Emergence of neuropsychiatric symptoms should prompt immediate stopping of bupropion and varenicline and continued monitoring until symptoms resolve

29 Minimising weight gain following cessation Average weight increases by 4.7kg one year following smoking cessation (Aubin, et al, 2012) Cochrane review highlighted that weight gain can be minimised through (Farley et al, 2012) setting target for weight gain controlling calorie intake regular exercise increasing physical activity at home 29

30 30 Role of primary and secondary care

31 Role of primary and secondary care Communicating how smoking cessation and reduction can improve both physical and mental health in both short and longer term Offer of combination NRT to all, including those who continue to smoke, to support smoking reduction if not abrupt cessation (NICE, 2013) Encourage engagement in group/ individual cessation counselling 31

32 Role of primary and secondary care upon smoking cessation Reduce doses of relevant drugs - requires clear communication and coordination between smoking cessation services and prescribers in primary and secondary care Monitor mental state following cessation - for those taking bupropion and varenicline clear negotiated plan of support especially in first 2-3 weeks which outlines actions in event of change in psychiatric symptoms Monitor for smoking resumption since this is common and requires prompt dose increases of some medications Advise smokers that secondary mental health settings are smokefree, interventions to support temporary abstinence and reduced smoking if the person is unwilling to stop smoking (NICE, 2013) 32

33 Smoking in the broader context of public mental health 33

34 34 Smoking in the context of public mental health Mental disorder accounts for at least 23% of disease burden (DALYs) in UK compared to 16% for cancer and 16% for cardiovascular disease (WHO, 2008) - 27% of disease burden (YLDs) (WHO, 2011) High burden due to: Almost 1 in 4 of adult population in England experiences at least one mental disorder each year (McManus et al, 2009) Majority of lifetime mental disorder arising before adulthood Broad range of impacts including on health risk behaviour (42% adult tobacco consumption) as well as physical health, life expectancy (10-20 year reduction), education, employment, 105 billion annual cost of mental disorder in England (CMH, 2010) Mental wellbeing has similar broad range of impacts yet significant proportion of population has poor mental wellbeing

35 Smoking in the context of public mental health Cost effective interventions exist (RCPsych, 2010; HMG, 2010; Campion & Fitch, 2012): Treatment of mental disorder Treatment and prevention of associated physical illness and health risk behaviour such as smoking Prevention of mental disorder Promotion of mental wellbeing Result in broad range of large impacts Associated economic savings even in the short term (DH, 2011/ Knapp et al, 2011) BUT low coverage is major problem 35

36 36 Assessment of level of unmet need to support commissioning

37 Context of assessment of smoking cessation need Smoking - largest single cause of premature death in people with mental disorder 42% of tobacco consumption by people with mental disorder (McManus et al, 2010) Almost 25% of adult population in England experience at least mental disorder in previous year 3% of adult population see secondary mental health services Majority with mental disorder except psychosis receive no treatment (McManus et al, 2009) 37

38 Importance of coordination with public health Local public health teams responsible for Joint Strategic Needs Assessments (JSNA) which outlines local level of unmet need JSNAs provide information about local levels of health and social care needs as well as information about broader determinants (DH, 2012) JSNAs informs actions which local authorities, local NHS and other partners need to take to improve health and wellbeing of local population However, mental health is poorly covered in JSNAs (Lavis & Olivia, 2013; Campion & Coombes, in press) 38

39 Coverage of public mental health intelligence in JSNA s UCLPartners audit of 23 JSNAs (Campion & Coombes, in press) covering 6 million population found public mental health intelligence inadequately and inconsistently covered - often only in passing when mentioned Child and adolescent conduct/emotional disorder mentioned in 50% JSNAs Adult mental disorder: depression mentioned in 72% of JSNAs, SMI 67%, personality disorder 28%, dementia 89% 39 Tobacco Linked to mental disorder in 44% JSNAs No JSNAs provided information about smoking cessation in people with mental disorder Mental wellbeing mentioned in 44% JSNAs Lack of information about size or impact of unmet public mental health need

40 UCLPartners mental health informatics platform Comprehensive mental health needs assessment to enable inclusion of most up to mental health intelligence in JSNAs Identifies local size, impact and cost of public mental health intervention gaps Identifies local opportunities to: treat mental disorder in primary and secondary care address physical health issues and health risk behaviour in people with mental disorder prevent mental disorder promote mental wellbeing 40 Whole system approach including public health, social care, primary care, secondary care, other providers

41 UCLPartners mental health informatics platform Benchmarks data against other local authorities, region and national levels Deprivation linkage Takes into account local levels of deprivation Correlates different data against deprivation Examines interaction between different sectors e.g. primary and secondary care Supporting number of local authorities covering population of more than 2 million 41 Complements PHE work on mental health

42 42 Local levels of smoking and associated harm

43 Smoking needs assessment as part of JSNA Local level of unmet smoking cessation need for people with mental disorder should be included in JSNAs estimated numbers of smokers including with mental disorder proportion receiving smoking cessation from primary care, secondary care, NHS Stop Smoking Services, pharmacies and other providers (NICE, 2013; Campion & Fitch, 2012) outcomes of services Informs service planning/ support CCGs to commission services Next slide highlights London borough variation in smoking prevalence, smoking attributable death rates and smoking in pregnancy 43

44 44 Local levels of smoking and attributable death

45 45 Local levels of smoking vs deprivation

46 Primary care: Information about number of smokers with long term conditions including SMI Next slide % of patients in primary care with any or combination of different long term conditions including SMI whose notes record smoking status in past 15 months QOF SMOKE05 BUT no routine estimates of numbers of smokers with different mental disorder despite level of tobacco consumption see slide after next 46

47 % of smokers with long term conditions including SMI whose notes record smoking status 47

48 48 Estimated numbers of smokers with different mental disorder by London borough

49 49 Local size of smoking cessation intervention gap

50 Size of primary care smoking intervention QOF shows that 82% of smokers in primary care in had a record of an offer of support and treatment within the preceding 27 months (HSCIC, 2013) next slide rates per borough (QOF) Similar rates for patients with long term conditions including SMI whose notes contain a record of smoking cessation advice or referral in past 15 months (QOF) 50

51 % of smokers aged 15 and over with offer of support and treatment in previous 27 months (QOF SMOKE08) 51

52 % of patients with long term conditions including SMI whose notes contain a record of smoking cessation advice or referral in past 15 months (SMOKE06) 52

53 Size of primary care smoking intervention gap 10% of smokers with mental disorder receive cessation medication in primary care (Szatkowski et al, 2013) Provision of smoking cessation interventions - lower per consultation for smokers with mental disorder compared with smokers without (Szatkowski et al, 2013) BUT no information collected about rates of intervention and outcomes for people with different mental disorder 53

54 Size of NHS Stop Smoking intervention gap 9% of adult smokers set a quit date through NHS Stop Smoking Services in which is 11% lower compared to 2011/12 (HSCIC, 2013) Local proportion of total smokers setting a quit date with NHS SSS varies by London borough from 2-14% see last column next slide Local proportion of smokers who set quit date who successfully quit varies by London borough 40-80% BUT no data on coverage for people with mental disorder 54

55 NHS Stop Smoking service coverage of smoking cessation interventions 55

56 NHS Stop Smoking service coverage of smoking cessation interventions 56

57 57 NHS Stop Smoking service successful quit rates

58 Proportion of total smokers setting a quit date and successfully quitting with NHS Stop Smoking services 58

59 Costs of NHS Stop Smoking service provision vs cost of doing nothing Local variation of costs per quitter between London boroughs Local variation in spend on NHS Stop Smoking services which varies million per London borough Compare with annual million cost of smoking per London borough 59

60 60 Local costs of NHS Stop Smoking services

61 61 Local annual cost of smoking by London borough

62 62 Summary

63 63 Summary Smoking - largest avoidable cause of premature death and health inequality in those with mental disorders who die years earlier than the general population Adults with mental disorders consume 42% of the tobacco in England and therefore disproportionately experience tobacco related harm With appropriate support, people with mental disorder are able to stop smoking Smoking cessation improves mental and physical health even in short term and reduces risk of premature death Impact of smoking cessation on mood and anxiety disorders at least as large as antidepressant treatment Stopping smoking requires immediate reduction of doses of some antidepressants, antipsychotics and benzodiazepines by up to 25% within 1st week and up to 50% within 4 weeks

64 Summary Large impact and associated cost of smoking which disproportionately affects people with mental disorder Cost effective interventions to support people stop and reduce smoking BUT poor coverage of smoking cessation interventions which results in large impacts and associated costs People with mental disorder receive lower rates of smoking cessation support despite higher smoking rates and associated lower life expectancy 64

65 Summary Range of public mental health intelligence relevant to commissioning of interventions in primary care, secondary care, public health and social care Public mental health intelligence inadequately covered in Joint Strategic Needs Assessments Public mental health intelligence provides understanding of local public mental health opportunities to improve population health in each sector Broad range of impacts with associated economic savings even in the short term which can be estimated at local level 65

66 Resources and contact McManus S, Meltzer H, Campion J (2010) Cigarette smoking and mental health in England. Data from the Adult Psychiatric Morbidity Survey. National Centre for Social Research Campion J, Fitch C (2012) Guidance for the commissioning of public mental health services. Joint Commissioning Panel for Mental Health Campion J (2013) Public mental health commissioning guidance: embedding mental health in local public health work. Perspectives in Public Health 133: 87 Lawn S, Campion J (2013) Achieving smoke-free mental health services: Lessons from the past decade of implementation research. Int J Environ Res Public Health 10: Campion J, Shiers D, Britton J et al (2014) Primary Care Guidance on Smoking and Mental Disorders 2014 update. Royal College of General Practitioners & Royal College of Psychiatrists j.campion@slam.nhs.uk j.campion@ucl.ac.uk 66

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