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Understanding Tobacco’s Deadly Tolls on Individuals, Families, and Communities

Understanding Tobacco’s Deadly Tolls on Individuals, Families, and Communities. Steven A. Schroeder, MD SAMHSA’s State Policy Academy on Tobacco Control in Behavioral Health June 19, 2014 Presentation courtesy of the Smoking Cessation Leadership Center and Rx for Change.

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Understanding Tobacco’s Deadly Tolls on Individuals, Families, and Communities

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  1. Understanding Tobacco’s Deadly Tolls on Individuals, Families, and Communities Steven A. Schroeder, MD SAMHSA’s State Policy Academy on Tobacco Control in Behavioral Health June 19, 2014 Presentation courtesy of the Smoking Cessation Leadership Center and Rx for Change

  2. The Health Consequences of Smoking:50 Years of ProgressA Report of the Surgeon General 1964 2014

  3. 50 Years of Tobacco ControlJAMA

  4. Facts About Smoking and Health

  5. Tobacco’s Deadly Toll • 480,000 deaths in the U.S. each year • 4.8 million deaths world wide each year • 10 million deaths estimated by year 2030 • 50,000 deaths in the U.S. due to second-hand smoke exposure • 16 million in U.S. with smoking related diseases • 45.3 million smokers in U.S. (78% daily smokers, averaging 13 cigarettes/day, 2012)

  6. * Also suffer frommental illness and/or substance abuse Behavioral Causes of Annual Deaths in the United States, 2000 435 Number of deaths (thousands) * * Sexual Alcohol Motor Guns Drug Obesity/ Smoking Behavior Vehicle Induced Inactivity Source: Mokdad et al, JAMA 2004; 291:1238-1245 Mokdad et al; JAMA. 2005; 293:293 7

  7. 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 Health Consequences of Smoking U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General, 2010.

  8. 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

  9. 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

  10. 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… $6.50 per day $45.00 per week $180 per month $2,160 per year $21,680 per 10 years Steinberg, 2004

  11. Compounds in Tobacco Smoke An estimated 7,000 compounds in tobacco smoke, including 69 proven human carcinogens Gases Particles • Carbon monoxide • Hydrogen cyanide • Ammonia • Benzene • Formaldehyde • Nicotine • Nitrosamines • Lead • Cadmium • Polonium-210 Nicotine does NOT cause the ill health effects of tobacco use.

  12. Causal Associations with Second-hand Smoke There is no safe level of 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 USDHHS. (2006).The Health Consequences of Involuntary Exposure to Tobacco Smoke: Report of the Surgeon General.

  13. Epidemiology of Tobacco Use

  14. TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2012 Trends in cigarette current smoking among persons aged 18 or older 18% of adults are current smokers Male Percent Female 21.0% 17.8% Year 70% want to quit Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2010 NHIS. Estimates since 1992 include some-day smoking.

  15. PREVALENCE of ADULT SMOKING, by EDUCATION—U.S., 2011 25.1% No high school diploma 45.3% GED diploma 23.8% High school graduate 22.3% Some college 9.3% Undergraduate degree 5.0% Graduate degree Centers for Disease Control and Prevention. (2012). MMWR 61(44);889-894.

  16. Smoking Prevalence and Average Number of Cigarettes Smoked per Day per Current Smoker 1965-2010* Percent/Number of Cigarettes Smoked Daily * Schroeder, JAMA 2012; 308:1586

  17. Smoking Prevalence by MH Diagnosis 2007 NHIS data • Schizophrenia 59.1% • Bipolar disorder 46.4% • ADD/ADHD 37.2% Current smoking: • 1 MH 31.9% • 2 MH 41.8% • 3+ MH 61.4% Grant et al., 2004, Lasser et al., 2000 • Major depression 45-50% • Bipolar disorder 50-70% • Schizophrenia 70-90%

  18. 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 is nearly 1.5 times the rate of death from other addiction-related causes (SAMHSA N-SSATS Report September 2013) • In 2011, < half (42%) of U.S. substance abuse treatment facilities —offered tobacco cessation services (SAMHSA N-SSATS Report September 2013)

  19. Smoking and theJustice Involved Population • 70 - 80% of men smoke; • 44 - 91% of women smoke • Prisoners have greater number of comorbidities, including MI and SA issues. • 97% of inmates in a smoke-free prison usually revert to smoking within six months of their release

  20. 30%-35% of Behavioral Health Health Providers Smoke Compared to general health care providersPrimary Care Physicians 1.7 %Emergency Physicians 5.7 %Psychiatrists 3.2 % Registered Nurses 13.1%Dentists 5.8 %Dental Hygienists 5.4 %Pharmacists 4.5 % NASMHPD Research Institute, Inc. (2006). Survey on Smoking Policies and Practices for Psychiatric Facilities. Strouse R, Hall J and Kovac M. Survey of Health Professionals' Knowledge, Attitudes, Beliefs, and Behaviors Regarding Smoking Cessation Assistance and Counseling. Princeton, N.J.: Mathematica Policy Research, Inc., 2004, 1-16.

  21. Benefits of Tobacco Control in the Unites States, 1964-2012* • 17.7 smoking-related deaths occurred • 8 million such deaths prevented • Preventing smoking-related deaths accounted for 30% of life expectancy gains during that period! • People with mental illness did not benefit as much from these declines in smoking rates * Holford et al ; Cook et al,JAMA, 2014

  22. NRI Survey *Response rates: 2005 – 55%, 2006 – 82%, 2008 – 75%, 2011 – 80% Source: Schacht L, Ortiz G, Lane M. Smoking Policies and Practices in State Psychiatric Hospitals 2011. National Association of State Mental Health Program Directors Research Institute, Inc. Feb 29, 2012.

  23. Clinical Issues

  24. 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) Prochaska, NEJM, July 21, 2011

  25. Dopamine Reward Pathway Prefrontal cortex Dopamine release Stimulation of nicotine receptors Nucleus accumbens Ventral tegmental area Nicotine enters brain

  26. 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 • Nicotine exposure heightens pleasure from cocaine in rat model (Science Trans Med, 11/2/2011)

  27. What is the Evidence that Anything Works?

  28. 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

  29. Ask. Advise. Refer. = 5 A’s Ask Ask. Every patient/client about tobacco use. Advise Assess Assist Advise. Every tobacco user to quit. Arrange Refer. Determine willingness to quit. Provide information on quitlines. Refer to Quitlines Portal to other services ADHA Smoking Cessation Initiative (SCI)

  30. Quitlines and Behavioral Health Do quitlines work for people with MI and/or SUD? Are they able to meet the demand?

  31. Behavioral Health Advisory Forum Screening and Training • NAQC standard optional question(s) for the Minimal Data Set* • Do you have any mental health issues or emotional challenges, such as an anxiety disorder, depression disorder, bipolar disorder, alcohol/drug abuse, or schizophrenia? • Do you believe that these mental health issues or emotional challenges will interfere with your ability to quit? • Developed a standardized training curriculum for quitline tobacco treatment specialists * Do Quitlines Have a Role in Serving the Tobacco Cessation Needs of Persons with Mental Illnesses and Substance Use Disorders? The Behavioral Health Advisory Forum (BHAF), Background Report, September 2010.

  32. 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 excluded patients with mental illness

  33. LONG-TERM (6 month) QUIT RATES for AVAILABLE CESSATION MEDICATIONS 28.0 23.9 18.9 18.9 17.1 16.3 15.9 Percent quit 12.0 11.8 10.6 10.0 9.8 9.1 8.4 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

  34. Treatment • Persons with mental illnesses and substance abuse disorders benefit by the same interventions as the general population • A 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

  35. Reduction vs. Abrupt Cessation in Smokers Who Want to Quit • There are two schedules to stop smoking BH population: immediate cessation versus gradual reduction. As of now, there is no clear evidence supporting one over the other. • Give smokers a choice as to whether they would prefer to abruptly quit or gradually reduce • Risks from lower intensity smoking are not much less than higher intensity. Source: Lindson, N., Aveyard, P., & Hughes J.R. (2010).  Reduction versus abrupt cessation in smokers who want to quit. Cochrane Database of Systematic Reviews, Issue 3.

  36. 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

  37. Conclusion and Next Steps

  38. Surgeon General’s Report Commission (2014) • Reduce smoking rates, currently at about 18 percent, to less than 10 percent within 10 years (“10 in 10”); • Protect all American from second hand smoke with five year; and • Ultimately eliminate the death and disease caused by tobacco use

  39. The Electronic Cigarette* • Aerosolizes nicotine in propylene glycol solvent • Cartridges contain about 20 mg nicotine • Safety unproven, but >cigarette smoke • Bridge use or starter product? • Probably deliver < nicotine than promised • Not FDA approved; predatory marketing • My advice: avoid unless patient insists *Cobb & Abrams. NEJM July 21, 2011; Fiore, Schroeder, Baker, NEJM Jan 23, 2014

  40. Smoking Profile, 2014 • Policymakers live in a non-smoking “gated community” • Smoking now marginalized to the poor and the disadvantaged, plus some “young immortals” • Thus tobacco control=social justice issue • Tobacco industry fights domestic rear guard action while expanding overseas

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