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___________________________________________________ Steven A. Schroeder, M.D., Director Smoking Cessation Leadership Cen

Understanding Tobacco’s Deadly Toll: Responding to the Call to Help People with Mental Illnesses and Addictions Live Smoke-Free SAMHSA 100 Pioneers. ___________________________________________________ Steven A. Schroeder, M.D., Director Smoking Cessation Leadership Center March 2009.

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___________________________________________________ Steven A. Schroeder, M.D., Director Smoking Cessation Leadership Cen

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  1. Understanding Tobacco’s Deadly Toll: Responding to the Call to Help People with Mental Illnesses and Addictions Live Smoke-FreeSAMHSA100 Pioneers ___________________________________________________ Steven A. Schroeder, M.D., Director Smoking Cessation Leadership Center March 2009

  2. The Smoking Cessation Leadership Center • Began in 2003 as a Robert Wood Johnson National Program Office with a $10-million, five-year grant • Aimed at helping clinicians do a better job intervening with tobacco users • Additional funding from VA, American Legacy Foundation • Recent foray into mental health and substance abuse arenas, from Legacy grant 2

  3. SCLC’s Aim • We want more smokers who want to quit to get the help and support they need to succeed • Access to cessation tools and resources needs to be widened for all groups • Health care providers have a special role • Examples: substance abuse counselors, dental hygienists, psychiatric nurses, physicians, mental health providers 3

  4. Tobacco’s Deadly Toll • 443,000 deaths in the U.S. each year • 4.8 million deaths worldwide each year • 10 million deaths estimated by year 2030 • 8.6 million disabled from tobacco in the U.S. alone 4

  5. * 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 5

  6. People with mental illness consume 44% of cigarettes smoked in U.S. 6

  7. Annual U.S. Deaths Attributable to Smoking, 2000–2004 Percent of all smoking-attributable deaths 29% 28% 23% 11% 8% <1% TOTAL: 443,595 deaths annually Centers for Disease Control and Prevention. MMWR 2008;571226–1228.

  8. Health Consequences of Smoking Cancers Acute myeloid leukemia Bladder and kidney Cervical Esophageal Gastric Laryngeal Lung Oral cavity and pharyngeal Pancreatic Pulmonary diseases Acute (e.g., pneumonia) Chronic (e.g., COPD) Cardiovascular diseases Abdominal aortic aneurysm Coronary heart disease Cerebrovascular disease Peripheral arterial disease Type 2 diabetes mellitus Reproductive effects Reduced fertility in women Poor pregnancy outcomes (e.g., low birth weight, preterm delivery) Infant mortality Other effects: cataract, osteoporosis, periodontitis, poor surgical outcomes, cognitive decline U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General, 2004.

  9. The Real Culprit • It is the smoke, tar, and additives that make people sicken and die. The nicotine is dangerous because it addicts people to tobacco. • Staff and patients in settings that allow smoking are being continually exposed to lethal substances. 9

  10. Causal Associations of Second Hand Smoke • Developmental • Low birth weight • Sudden infant death • Pre-term delivery • Carcinogenic • Lung cancer • Nasal sinus cancer • Breast cancer (younger, premenopausal women) • Respiratory • Asthma induction and exacerbation • Eye and nasal irritation • Bronchitis, pneumonia, otitis media in children • Cardiovascular • Heart disease mortality • Acute and chronic coronary heart disease morbidity • Altered vascular properties 10

  11. Compounds in Tobacco Smoke An estimated 4,800 compounds in tobacco smoke Gases Particles • Carbon monoxide • Hydrogen cyanide • Ammonia • Benzene • Formaldehyde • Nicotine • Nitrosamines • Lead • Cadmium • Polonium-210 11 proven human carcinogens 11

  12. Nicotine Distribution Nicotine reaches the brain within 11 seconds Arterial Venous Henningfield et al., Drug Alcohol Depend1993;33:23-29. 12

  13. Dopamine Reward Pathway Prefrontal cortex Dopamine release Stimulation of nicotine receptors Nucleus accumbens Ventral tegmental area Nicotine enters brain 13

  14. Cigarette Smoking, Adults 18 Years and Over Source: Behavioral Risk Factor Surveillance Survey, NCCDPHP, CDC

  15. Lung Cancer Deaths 2003-2005 Source: National Vital Statistics System—Mortality, CDC, NCHS

  16. TRENDS in ADULT SMOKING, by SEX—U.S., 1955–2007 Trends in cigarette current smoking among persons aged 18 or older 19.8% of adults are current smokers Male Percent Female 22.3% 17.4% Year 70% want to quit including MH Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2005 NHIS. Estimates since 1992 include some-day smoking.

  17. PREVALENCE of ADULT SMOKING, by RACE/ETHNICITY—U.S., 2007 36.4% American Indian/Alaska Native* 21.4% White* 19.8% Black* 13.3% Hispanic 9.6% Asian* * non-Hispanic. Centers for Disease Control and Prevention. (2008). MMWR 57:1221–1116.

  18. PREVALENCE of ADULT SMOKING, by EDUCATION—U.S., 2007 24.8% No high school diploma 44.0% GED diploma 23.7% High school graduate 20.9% Some college 11.4% Undergraduate degree 6.2% Graduate degree Centers for Disease Control and Prevention. (2008). MMWR 57:1221–1116.

  19. Smoking Prevalence Among Those with Mental Illness • Prevalence is 75% for those with either addictions and/or mental illness, as opposed to 19.8% for the general population • In mental health settings, about 30-35% of the staff smoke 19

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

  21. Smoking Cessation: Reduced Risk of Death • Prospective study of 34,439 male British doctors • Mortality was monitored for 50 years (1951–2001) On average, cigarette smokers die approximately 10 years younger than do nonsmokers. Years of life gained Among those who continue smoking, at least half will die due to a tobacco-related disease. Age at cessation (years) Doll et al. (2004). BMJ 328(7455):1519–1527.

  22. Cumulative risk (%) Reduction in Cumulative Risk of Death from Lung Cancer in Men Age in years 22 Reprinted with permission. Peto et al. (2000). BMJ 321 (7257): 323–329.

  23. Smoking Cessation Attempts Adults 18 Years and Over Source: National Health Interview Survey, CDC, NCHS

  24. 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 Most drug trials exclude patients with mental illness Sharon Hall (UCSF) studies show 50% 52-wk point-prevalence cessation after long-term drug use plus extended counseling (“cold turkey” rates <5%, most drug trials <25%)

  25. Long Term (6 month) Quit Rates for Available Cessation Medications 23.9 22.5 20.0 19.5 17.1 16.4 14.6 Percent quit 11.8 11.5 10.2 9.4 9.1 8.8 8.6 Data adapted from Silagy et al. (2004). Cochrane Database Syst Rev; Hughes et al., (2004). Cochrane Database Syst Rev.; Gonzales et al., (2006). JAMA and Jorenby et al., (2006). JAMA 25

  26. Smoking and Mental Illness: The Heavy Burden 200,000 of the 435,000 annual deaths from smoking occur among patients with CMI and/or substance abuse This population consumes 44% of all cigarettes sold in the United States -- higher prevalence -- smoke more -- more likely to smoke down to the butt People with CMI die on average 25 years earlier than others, and smoking is a large contributor to that early mortality Social isolation from smoking compounds the social stigma

  27. Issues: Smokers with Mentaland Addictive Disorders • Neurobiological factors reinforce use of nicotine • Feel excluded from mainstream cessation programs • Lower rates of quit attempts • Higher tobacco relapse rates 27

  28. Issues: Smokers with Mental and Addictive Disorders (2) • Long considered part of psychiatric culture • Clinicians believe consumers are not able/willing to quit • For those with chronic mental disorders • Major part of daily routine/structure • Alleviates boredom 28

  29. Mental and Addictive Disorders and Quit Rates • Quit rates among those with current MH diagnoses are lower than for those with no history of mental illness • Quit rates among smokers with a history of alcohol and substance abuse and social phobias are lower than for those without this history 29

  30. Key Factors in Treatment of Smokers with Mental Illness and/or Addictions • Timing- concern, but no clear guidelines, about when to introduce treatment during periods of acute psychiatric stress • Increasing evidence that treatment does not hurt recovery and may improve outcomes • Varenicline controversy 30

  31. Treatment Options for Smokers • Counseling Peer support, providers, quitlines • Pharmacotherapy 31

  32. Pharmacologic Methods: First-line Therapies Three general classes of FDA-approved drugs for smoking cessation: Nicotine replacement therapy (NRT) • Nicotine gum, patch, lozenge, nasal spray, inhaler Psychotropics • Sustained-release bupropion Partial nicotinic receptor agonist • Varenicline 32

  33. Mental Health Benefits From Treating Tobacco Dependence • Reduction of morbidity • Enhanced abstinence from substance use • Reduced financial burden • Increased self-confidence • Increased focus on mental health and wellness • Reduced stigma 33

  34. Past Year Mental Health Care among Adults with Both Serious Psychological Distress and a Substance Use Disorder: 2007 Substance Abuse and Mental Health Services Administration, Office of Applied Studies (2008). Results from the 2007 National Survey on Drug Use and Health: National Findings (NSDUH Series H-34, DHHS Publication No. SMA 08-4343). Rockville, MD.

  35. Cigarette Smoking Association with Illicit Drug and Alcohol Use in 2007 • Current drug use reported by 20.1% of smokers vs. 4.1% of nonsmokers • Alcohol use reported by 66.9% of smokers vs. 46.1% of nonsmokers • Binge drinking reported by 45% of smokers vs. 16.4% of nonsmokers • Heavy drinking reported by 16.4% of smokers vs. 3.8% of nonsmokers Substance Abuse and Mental Health Services Administration, Office of Applied Studies (2008). Results from the 2007 National Survey on Drug Use and Health: National Findings (NSDUH Series H-34, DHHS Publication No. SMA 08-4343). Rockville, MD. 35

  36. Substance Dependence or Abuse in 2007 • An estimated 22.3 million adults classified with substance dependence or abuse-9.0% of the population. Of these— -3.2 million dependent on/abused alcohol and drugs -3.7 million dependent on/abused drugs but not alcohol -15.5 million dependent on/abused alcohol but not drugs Substance Abuse and Mental Health Services Administration, Office of Applied Studies (2008). Results from the 2007 National Survey on Drug Use and Health: National Findings (NSDUH Series H-34, DHHS Publication No. SMA 08-4343). Rockville, MD. 36

  37. Smoking and Alcohol Dependence • Over 72% of alcoholics are heavy smokers (9% of general pop) • Increased urge to drink among alcoholic smokers when they smell cigarettes • Dawson, 2000 37

  38. Smoking Cessation Treatment for Alcohol Users • Standard treatments effective • No evidence of increased use of other substances during cessation treatment • Alcohol abstinence days greatest for those who quit smoking • Saxon, 2003 • Kohn, 2003 38

  39. Reasons for Not Receiving Substance Use Treatment among Persons Aged 12 and Older: 2004-2007 Combined Substance Abuse and Mental Health Services Administration, Office of Applied Studies (2008). Results from the 2007 National Survey on Drug Use and Health: National Findings (NSDUH Series H-34, DHHS Publication No. SMA 08-4343). Rockville, MD. 39

  40. Journal of the American Psychiatric Nurses Association

  41. Journal of the American Medical Associationarticle

  42. Power of Intervention • ⅓to ½ of the 44.5 million smokers will die from the habit. Of the 31 million who want to quit, 10 to 15.5 million will die from smoking. • Increasing the 2.5% cessation rate to 10% would save 1.2 million additional lives. • If cessation rates rose to 15%, 1.9 million additional lives would be saved. • No other health intervention could make such a difference! 42

  43. Thank Youhttp://smokingcessationleadership.ucsf.eduToll-free technical assistance 1-877-509-3786JAMA article:http://jama.ama-assn.org/cgi/content/full/301/5/522 Special thanks to: Gail Hutchings, M.P.A. Behavioral Health Policy Collaborative and Eric Heiligenstein, M.D., Clinical Director Psychiatry Service, University Health Services Associate, CTRI, University of Wisconsin-Madison

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