Smoking Cessation in Mental Health and Primary Care Practice 13 th Annual Statewide Integrated Care Conference Integrating Substance Use, Mental Health, and Primary Care Services: Courageous and Compassionate Care Steven A. Schroeder, MD Distinguished Professor of Health and Health Care Department of Medicine, UCSF Director, Smoking Cessation Leadership Center 10/19/2016
Disclosure Dr. Steven Schroeder does not have relevant financial relationships with commercial interests.
The Health Consequences of Smoking: 50 Years of Progress A Report of the Surgeon General 1964 2014
50 Years of Tobacco Control JAMA
It s a New Era
Tobacco s Deadly Toll 540,000 deaths in the U.S. each year* 4.8 million deaths world wide each year --Current trends show >8 million deaths annually by 2030 42,000 deaths in the U.S. due to second-hand smoke exposure 14 million in U.S. with smoking related diseases (60% with COPD) 42.1 million smokers in U.S. (76.9% daily smokers, averaging 14.2 cigarettes/day, 2013) * Carter et al, NEJM, Feb 12, 2015
Percent 60 TRENDS in ADULT SMOKING, by SEX U.S., 1955 2014 Trends in cigarette current smoking among persons aged 18 or older 50 40 Male Male 15.1% of adults are current smokers 30 20 10 Female Female 18.8% 14.8% 0 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 68.9% want to quit Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965 2014 NHIS. Estimates since 1992 include some-day smoking. * 2015 early NHIS data
Percent/Number of Cigarettes Smoked Daily Smoking Prevalence and Average Number of Cigarettes Smoked per Day per Current Smoker 1965-2010 *January-March 2015: 15.3% prevalence! Source: Schroeder, JAMA 2012; 308:1586; *CDC/NCHS, National Health Interview Survey, 1997-March 2015, Sample Adult Core
Behavioral Causes of Annual Deaths in the United States, 2000 450 400 350 300 250 200 150 100 50 0 20 85 43 29 17 365 Sexual Alcohol Motor Guns Drug Obesity/ Smoking Behavior Vehicle Induced Inactivity 112 435 * Source: Mokdad et al. JAMA 2004;291:1238-1245; Mokdad et al. JAMA. 2005; 293:293 Flegal KM, Graubard BI, Williamson DF, Gail, MH. Excess deaths associated with underweight, overweight, and obesity. JAMA 2005;293:1861-1867 * Also suffer from mental illness and/or substance abuse
U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General, 2010. Health Consequences of Smoking Cancers Acute myeloid leukemia Bladder and kidney Cervical Colon, liver, pancreas Esophageal Gastric Laryngeal Lung Oral cavity and pharyngeal Prostate ( survival) Pulmonary diseases Acute (e.g., pneumonia) Chronic (e.g., COPD) Tuberculosis Cardiovascular diseases Abdominal aortic aneurysm Coronary heart disease Cerebro-vascular disease Peripheral arterial disease Type 2 diabetes mellitus Reproductive effects Reduced fertility in women Poor pregnancy outcomes (ectopic pregnancy, congenital anomalies, low birth weight, preterm delivery) Infant mortality; childhood obesity Other effects: cataract; osteoporosis; Crohns; periodontitis,; poor surgical outcomes; Alzheimers; rheumatoid arthritis; less sleep
Causal Associations with Second-hand Smoke Developmental Low birthweight Sudden infant death syndrome (SIDS) Pre-term delivery -- Childhood depression Respiratory Asthma induction and exacerbation Eye and nasal irritation Bronchitis, pneumonia, otitis media, bruxism in children Decreased hearing in teens Carcinogenic Lung cancer Nasal sinus cancer Breast cancer? (younger, premenopausal women) Cardiovascular Heart disease mortality Acute and chronic coronary heart disease morbidity Altered vascular properties There is no safe level of second-hand smoke. USDHHS. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General.
The Toll from Smoking: An Apparent Paradox As prevalence declines, toll increases Reason is increased appreciation of damage caused by smoking, esp. COPD Estimates of annual deaths and morbidity should soon plateau and then fall, but still at very high rate of damage
Smoking and Behavioral Health: The Heavy Burden 200,000 annual deaths from smoking occur among patients with CMI and/or substance abuse This population consumes 40% of all cigarettes sold in the United States -- higher prevalence -- smoke more -- more likely to smoke down to the butt People with CMI die earlier than others, and smoking is a large contributor to that early mortality Greater risk for nicotine withdrawal Social isolation from smoking compounds the social stigma
Sources: http://cms.samhsa.gov/newsroom/press-announcements/201303200900 http://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/tobacco.html http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm Tsai & Rosenheck, Psychiatric Services, 2012; Parker et al., Addict Med, 2014. Vulnerable Populations Higher smoking rates have persisted among: Individuals with mental and/or SU disorders (38%) The poor (below poverty level: 29%; Medicaid: 37%) Least educated (GED: 41%; Less than H.S.: 24%) LGBT persons (27%) Chronically homeless (80%) Incarcerated persons (70% 83%) HIV infected (50%)
Industry Targets BH population Pushed Doral to homeless shelters, and psychiatric facilities R.J. Reynolds &"consumer subcultures, (gay/castro)" and "street people Sub Culture Urban Marketing
Smoking Prevalence and Substance Abuse 53-91% of people in addiction treatment settings use tobacco (Guydish et al, Nicotine and Tobacco Research, June 2011, p 401) Tobacco use causes more deaths than the alcohol or drug use bringing clients to treatment: death rates among tobacco users nearly 1.5 times the rate of death from other addiction-related causes (SAMHSA N-SSATS Report September 2013) Stopping smoking increases odds of abstinence (SAMHSA N- SSATS Report September 2013)
How Can You Help Smokers to Quit?
Dopamine Reward Pathway Prefrontal cortex Dopamine release Nucleus accumbens Ventral tegmental area Stimulation of nicotine receptors Nicotine enters brain
Nicotine Addiction Tobacco users maintain a minimum serum nicotine concentration in order to Prevent withdrawal symptoms Maintain pleasure/arousal Modulate mood Users self-titrate nicotine intake by Smoking more frequently Smoking more intensely Obstructing vents on low-nicotine brand cigarettes
Tools for Smoking Cessation 5A s (Ask, Advise, Assess, Assist, Arrange) AAR (Ask, Advise, Refer) Quitlines NRT and other medications Counseling and behavioral change strategies Peer-to-peer intervention
Responses to Patient Who Smokes Unacceptable: I don t have time. Acceptable Refer to a quit line and/or web program Establish systems in your office and hospital Become a cessation expert
Tobacco Dependence Treatment Persons with mental illnesses and substance use disorders benefit from same interventions as general population Combination of counseling and pharmacotherapy should be used whenever possible Duration of treatment might be longer View failed quit attempt as a practice, not failure
TOBACCO DEPENDENCE: A 2-PART PROBLEM Tobacco Dependence Physiologic Behavioral The addiction to nicotine Treatment The habit of using tobacco Treatment Medications for cessation Behavior change program Treatment should address the physiologic and the behavioral aspects of dependence.
PHARMACOTHERAPY Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations* for which there is insufficient evidence of effectiveness. * Includes pregnant women, smokeless tobacco users, light smokers, and adolescents. Medications significantly improve success rates. Fiore et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS, May 2008.
Pharmacologic Methods: First-line Therapies* Three general classes of FDA-approved medications for smoking cessation: Nicotine replacement therapy (NRT) -- nicotine gum, patch, lozenge, nasal spray, inhaler Partial nicotine receptor agonist -- varenicline --? cytisine in the future Psychotropics -- sustained-release bupropion * Counseling plus meds better than either alone Currently, no medications have an FDA indication for use in spit tobacco cessation.
Caveats About Cessation Literature Smoking should be thought of as a chronic condition, yet drug treatment often short (12 weeks) in contrast to methadone maintenance Great spectrum of severity and addiction; treatment should be tailored accordingly Volunteers for studies likely to be more motivated to quit Placebo and drug groups tend to have more intensive counseling than found in real practice world; and counseling is not a monolithic black box Most drug trials exclude patients with mental illness
Percent quit LONG-TERM ( 6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS 30 25 Active drug Placebo 23.9 28.0 20 15 10 16.3 15.9 10.0 9.8 18.9 8.4 11.8 17.1 9.1 18.9 10.6 12.0 5 0 Nicotine gum Nicotine patch Nicotine lozenge Nicotine nasal spray Data adapted from Cahill et al. (2012). Cochrane Database Syst Rev; Stead et al. (2012). Cochrane Database Syst Rev; Hughes et al. (2007). Cochrane Database Syst Rev Nicotine inhaler Bupropion Varenicline
Financial Impact People with mental illnesses and/or addictions may spend up to 1/3 their income on cigarettes* A pack a day smoker spends on average $5.51** per day $38.57 per week $154.28 per month $1,851.36 per year $18,513.60 per 10 years *Steinberg, 2004 **Average national price 2015 (American Lung Association)
Myths About Smoking and Behavioral Health Tobacco is necessary self-medication (industry has supported this myth) They are not interested in quitting (same % wish to quit as general population) They can t quit (quit rates same or slightly lower than general population) Quitting worsens recovery from the mental illness (not so; and quitting increases sobriety for alcoholics) It is a low priority problem (smoking is the biggest killer for those with mental illness or substance abuse issues) Source: Prochaska, NEJM, July 21, 2011
Power of Peers Peer-led support groups, community referrals, etc. Train peers to integrate tobacco cessation & wellness services into existing roles and responsibilities. Embedded model uses programs that have peer specialists on staff or as volunteers
New Cautions About Varenicline In addition to older concerns about increased suicide risks (rare but possible causation) and cardiac rhythm problems (controversial) New March 2015 warnings about potential for rare seizures and lower alcohol tolerance
2016 EAGLES Study Shows Varenicline Safety* Large RCT, with 1026 psychiatric pts receiving varenicline No increase in psychiatric symptoms, but much greater smoking cessation FDA considering whether to retain black boxed warning, but FDA reviewers currently questioning efficacy of EAGLES Study (not all adverse events noted) 2 FDA panels advise removing black boxed warning for neuropsychiatric risks (September 2016) * Anthenelli et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled
Tapering as a Way to Quit JAMA Feb 17, 2015: Varenicline for 24 weeks with intent to reduce daily #cigs by 50% within 4 weeks, 75% by 8 weeks, and quit attempt at week 12 By week 52, continuous abstinence = 27% for V, 10% for control. Much greater reduction of daily cigs by weeks 4 and 8 for V group
Evidence Review* shows Stopping Smoking Increases MH Cochrane Collaborative meta-analysis of 26 papers Smoking cessation leads to: depression, anxiety, stress and mood and quality of life Effect sizes of smoking cessation > or = anti-depressive drugs for mood or anxiety disorders * Taylor et al, BMJ, 2014
Quitlines and Behavioral Health Do quitlines work for people with MI and/or SUD? Are they able to meet the demand?
% Smoking Self-Reported Mental Health Issues Among Helpline Callers 60 50 40 30 20 10 36.9 27.8 16.1 7.1 5.2 48.9 0 Depression (Zhu,et al, 2009. Unpublished data) Anxiety Bipolar Schizophrenia Drug/Alcohol Any
Conclusion and Next Steps
Smoking Profile, 2016 Most policymakers live in a non-smoking gated community Smoking now marginalized to poor and disadvantaged, plus some young immortals Thus tobacco control=social justice issue New products/markets: e-cigs and marijuana Tobacco industry fights domestic rear guard action while expanding overseas
The Electronic Cigarette* Aerosolizes nicotine in propylene glycol soluent; e-cig products in evolution Nicotine content in cartridge varies Safety unproven, but >cigarette smoke Probably deliver < nicotine than promised Unclear if help smokers quit Not approved by FDA My advice: avoid unless patient insists September 2016: Cochrane review suggests that e-cigarettes can help people quit smoking; also no noted health side effects from vapers up to 2 years >50% of teen vapers only use flavoring, not nicotine** * Cobb & Abrams. NEJM July 21, 2011; Fiore, Schroeder, Baker, NEJM Jan 23, 2014
Cigarette and E-Cigarette Use among High School Students, 2000-2014 Source: Youth Risk Behavior Survey
Schroeder Conclusions regarding Electronic Cigarettes Products evolving, so risk reports dated Data on smoking cessation efficacy unclear;? 15% or so Much safer than combustible cigs (British MDs: 5% risk) Riskier than room air Second hand exposure less dangerous than regular cigs, but should not expose others in closed spaces Flavored marketing targets youth; should ban Nicotine exposure to adolescent brain unwise Ideal solution=cessation, but keep away from youth No evidence large scale gateway