The multiple roles of Behavioral Health consultants in smoking cessation

1. Session #__B5a___ Saturday, October 12, 2013 The multiple roles of Behavioral Health consultants in smoking cessation David R. Strong, PhD Associate Professor Department of Family and Preventive Medicine University of California, San Diego Collaborative Family Healthcare Association 15th Annual Conference October 10-12, 2013 Broomfield, Colorado U.S.A.

2. Faculty Disclosure Funding provided by: The California Tobacco Related Disease Research Program (21XT-0076) I have not had any relevant financial relationships during the past 12 months.

3. Objectives Describe factors that contribute to the feasibility of concurrent mental health and tobacco cessation treatment Discuss the role of behavioral health providers in smoking cessation efforts Describe the mechanisms by which clinical staff members can be leveraged to identify and treat patients

4. Background Despite persistent tobacco control efforts, the prevalence of smoking among those reporting symptoms of mental health problems has not declined in step with unaffected smokers. Smokers in California with mental health problems (MHP) are 2.5 times more likely to be current heavy smokers and are 50% less likely to quit successfully than other smokers. To decrease prevalence of tobacco related illness, targeting vulnerable populations disproportionately affected by disease and improving cessation outcomes is a key to public health impact.

5. US Smoking Rates Persistently Higher For Those Reporting Mental Health Problems

6. Rates of Quitting Remains Lower Among US Smokers Reporting Mental Health Problems Quit Ratio = % of Ever Smokers who have quit smoking National Health Interview Survey (NHIS)

7. Why Focus on Primary Care? 1) High prevalence of mental health concerns • Primary care MD’s write 2 out of 3 prescriptions for antidepressants in the US • Universal screening for depression and tobacco 2) High proportion of smokers visit primary care each year (reach is high) • 70% of smokers report contact with primary care 3) Access to evidence based care 4) Access to behavioral health with Collaborative Care Providers

8. Primary Care Intervention for Tobacco Use • Public Health Model • Screening, Brief Intervention and Referral to Treatment (SBIRT; SAMSHA) • Implement US Tobacco Treatment Guidelines: • Ask, Advise, Assess, Assist, Arrange • Evaluation of US practice • Although majority of US smokers Asked, Advised, and Assessed only 20.9% received Assistance or had follow-up Arranged (Jamal et al., 2012)

9. Advising Smokers to Quit • Strong evidence from 17 clinical trials that MD advise increases quit attempts • 1.66 higher odds compared to no advise (pooled OR) • Emerging evidence suggests smokers who report mental health problems may be primed to make quit attempts • 2011 California Longitudinal Smokers Study (CLSS). • Sample of smokers representative of the statewide population (n=1961).

10. Percent of smokers who try to quit after receiving advice to quit from a healthcare provider Smokers screening positive for mental health problems were more likely to try to quit after advice from PCP

11. Quitting for smokers with mental health problems: Promote Assist and Arrange • US Guidelines suggest medication and behavioral counseling • Evidence from 31 trials with patients from healthcare settings suggests that when compared to brief advice combined treatment doubles (OR= 2.2, 95%CI=1.81 to 2.34) the odds of success. • Use of Electronic Health Record increases referral to counseling (Linder et al ,2007) although rates in the US remained low (4%). • Among smokers who make attempts, still most common to observe unaided quit attempts which have the lowest success rate (~7%)

12. In 2011 California Statewide Survey: Method used to quit smoking

13. Quitting smoking: A long-term process Even with evidence based care: • Relapse rates are high • Multiple contacts may be needed • Support for a chronic care model (Joseph et al, 2011). • Receiving up to 18-months of follow-up after 5-sessions of phone-counseling and medication yielded higher quit success than no follow-up care. (30% vs. 23%)

14. AIMS • Evaluation of current practice: • Screening: Mental health + Smoking • Rates of referral for smoking cessation service • NRT vs. front line medication • Behavioral counseling (Quit Line) • Outcomes: • Record patient reports of cessation • Record reports of return to smoking

15. University of California, San Diego • Department of Family and Preventive Medicine • Three Family Medicine Clinics • Services 35,000+ patients • Each clinic:120-160 daily patient encounters • Population: • 56% female • 53% Caucasian, 28% Hispanic, 12% Asian/Pac Islander, 7% African Am. • Payors from low SES and Medi-Cal to PPO  • Integrated Primary Care • Patient-Centered Medical Home • Stepped-Care Behavioral Health Program • Integrated PCBH (T-CARE) • Targeted, • Collaborative, • Assessment, • Response, and • Empowerment • Specialty Mental Health

16. Methods • The current study extends efforts to increase understanding of the prevalence of tobacco use among patients reporting mental health problems. • Monitor screening and identification of prevalence across Hispanic, African American, and White smokers in primary care. • Electronic medical records of 28,132 patients visiting one of three UCSD Family Medicine clinics in 2011 were evaluated.

17. Screening and Assessment: Mental Health and Tobacco Use Patient Health Questionnaire (PHQ-2) • Rates of screening • Rates of positive screens Tobacco Use • Clinical reminders to document status • Current smoking status each visit

18. Screening For Tobacco Consistent Across Age, Racial groups (~90%)

19. Variability in Rates of Lifetime Tobacco use in Ethnic/Racial Groups

20. Rates of Current Tobacco Use Among those with Positive Depression Screens (PHQ-2) Having a Positive PHQ-2: OR = 2.85 ( 2.43-3.34), p<0.001 Adjusted for age, racial/ethnic group, and gender

21. Quit Ratio: Percent of Ever Smokers Who Are Now Not Smoking Having a Positive PHQ-2: OR = 0.43 ( 0.35-0.52), p<0.001 Adjusted for age, racial/ethnic group, and gender

22. Quit Attempts In the Past Year Having a Positive PHQ-2: OR = 0.78 ( 0.55-1.11), p=0.17 Adjusted for age, racial/ethnic group, and gender

23. Current Smokers Use of Prescriptions for Tobacco Dependence (n=2409) Positive Screens More Likely to Receive Prescription: OR = 1.73 (1.17-2.53), p<0.006 Adjusted for age, racial/ethnic group, and gender

24. Percent of Current Smokers (n=2409) In Collaborative Care Many smokers screening positive for mental health problems are already connected with Collaborative Care

25. Percent of Current Smokers Reporting A Recent Quit Attempt Positive screens and those in CC were similarly likely to report quitting in the past year: OR = 0.77 (0.54-1.10) (PHQ) OR = 1.09 (0.67-1.77), p=0.7 (CC)2 Adjusted for age, racial/ethnic group, and gender

26. Summary Rate of current smoking was higher for patients with PHQ+ across ethnic and racial groups Rates of quit attempts was similar for PHQ+ and PHQ- smokers PHQ+ smokers were more likely to use medication to quit Among PHQ+ patients, rate of quitting smoking successfully was significantly lower (62.65 vs. 70.3%) Many current smokers are connected to collaborative care where behavioral counseling for cessation can be facilitated

27. Multiple Roles for Behavioral Health Consultants a) Screening tobacco b) Screening depression c) Implement brief intervention (Five A’s) d) Develop awareness of comorbid mental health issues e) Identify opportunities for facilitating engagement • Motivational Intervention to promote evidence-based care f) Provide opportunity for behavioral counseling onsite g) Follow-up on any referral to helpline (phone counseling) h) Think of creative means of conveying skills for cessation • Handouts, texting programs, engage national resources

28. Roles for Behavioral Health Consultant

29. How to Help: Training Resources & Tools for Providers

30. Overview of Resources • 1. Provider/Patient Resources • Resource Cards • Toolkits • 2. Webinars • 3. Continuing Education (CE) Cessation Courses • 4. Online Courses/Programs • 5. Virtual Clinics

31. Provider/Patient Resources • Resource Cards: National Portal to Telephone-based Quitline Services • 1-800-Quit-Now seamlessly directs calls to the appropriate state quitline. The Smoking Cessation Leadership Center has developed a small, plastic card the size of a credit card to help promote the national portal, 1-800-Quit-Now. • National Asian-language Quitline Services are available through language-specific toll free numbers. Services are provided in Chinese, Korean, and Vietnamese by counselors housed at the California quitline. Recently, a Spanish-language portal was launched to connect callers with Spanish-language quitline services in their states.).

32. Provider/Patient Resources • Toolkits: • Destination Tobacco-Free: A Practical Tool for Hospitals and Health Systems -A national partnership of health leaders launched a new tool to help hospital executives and others develop best-practices in tobacco-use policies and protocols. • Smoking Cessation for Persons with Mental Illness—A Toolkit for Mental Health Providers-offers step-by-step instructions for providers to help consumers with mental illness quit smoking.

33. Webinars • Smoking Cessation Leadership Center (SCLC) • 12 webinars covering topics around tobacco addiction and recovery • Example: “Challenges in Tobacco Use Prevention in Youth”; “Understanding Tobacco’s Deadly Toll” • Tobacco Free Coalition- Every Smoker, Every Time Webinar • An online learning activity that provides strategies to help patients quit using tobacco • Successful completion is worth one AMA PRA Category 1 CME credit.

34. Continuing Education (CE) Cessation Courses • American Academy of Family Physicians –Ask and Act Initiative Treating Tobacco Dependence • Free one-hour online CME course from Center for Tobacco Research and Intervention (5 web-based modules) • American Society of Health-Systems Pharmacists- Tobacco Cessation Counseling- protocol for Pharmacists • Available to pharmacists and physicians

35. Online Courses/Programs • The National Centre for Smoking Cessation and Training (NCSCT) Training and Assessment Programme • Evidence based course developed to delivery guidance documents on competences required for the role of stop smoking practitioners. • These competences were used to develop the NCSCT Knowledge (Stage 1) and Practice (Stage 2) • Rx for Change: Clinician-Assisted Tobacco Cessation • Comprehensive tobacco cessation training program that equips health professional students and practicing clinicians, of all disciplines, with evidence-based knowledge and skills for assisting patients with quitting. • seven available versions: the 5 A's (comprehensive counseling); Ask-Advise-Refer (brief counseling); Psychiatry; Cancer Care Providers; Cardiology Providers; Mental Health Peer Counselors; &Surgical Providers

36. Virtual Clinics • Smoking Cessation For Pregnancy And Beyond: A Virtual Clinic • Online training, based on the "Virtual Practicum" model. The training is intended for health care professionals who will be assisting their female patients in quitting smoking, in particular, patients who are pregnant or in their child-bearing years.  • Allows you to "interview" real patients working with smoking cessation issues.

37. Learning Assessment Audience Question & Answer Are rates of smoking higher? Are interests in quitting lower? Are rates of success similar? Is treatment utilization the same?

38. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!