Wendy Bjornson, MPH

1. Meeting the Challenge of Tobacco Cessation for Persons with Homelessness, Mental Illnesses and Substance Abuse Disorders Wendy Bjornson, MPH Director, Tobacco Cessation Leadership Network; Oregon Health and Science University Smoking Cessation Center www.tcln.org

2. Oregon

3. Mt. Hood, Oregon

4. Oregon Coast

5. Portland, Oregon

6. Reducing Tobacco Use as a National Public Health Priority

7. Healthy People 2010 Goals

8. Current Cigarette Smoking (%) in Among Adults: 2006-2007 Source: Cigarette Smoking Prevalence and Policies in the 50 States. Robert Wood Johnson Foundation, 2009

9. CDC Office on Smoking and Health Guide for Comprehensive State Tobacco Control Programs

10. US Trends in Cigarette Smoking Among Adults Aged 18 Years or Older, by Poverty Status: 1983 - 2007 Source: Cigarette Smoking Prevalence and Policies in the 50 States. Robert Wood Johnson Foundation, 2009

11. Mental Health System • US Mental health care and general health care – separate delivery systems. • National call for better coordination between systems. • Tobacco cessation integrated into general health care, esp. primary care. • Professional training • Quality measures • Reimbursement • Wellness movement in mental health care.

12. Morbidity and Mortality National Association of State Mental Health Program Directors, Medical Directors Council, published a report in 2006 detailing statistics about morbidity and mortality among people with MI/SUD. Tobacco use was identified as a key risk factor.

13. Alarming Statistics • Persons with MI/SUD die up to 25 years earlier and suffer increased disease . • Greatly elevated risk for: Cardiovascular disease Respiratory disease Lung cancer Infections Diabetes • Mobilized mental health system on tobacco issues.

14. Tobacco Use and Psychiatric Disorders • 20% of Americans have MI/SUD (not including tobacco addiction). • Nicotine dependence 2 to 3 times more common. • 75% vs. 23% in general population. • This population consumes 44% of all the cigarettes in the United States.

15. Est. 200,000 per year for persons with MI/ SUD Source: CDC

16. State Programs Respond

17. Major Smoke-free Air Legislation in the 50 States and the District of Columbia –1991-2008 Source: Cigarette Smoking Prevalence and Policies in the 50 States. Robert Wood Johnson Foundation, 2009

18. Smoke Free Policy Movement • The momentum is building. • Smoking is now banned in many public places: • In workplaces where over 60% of Americans are employed. • Increasingly in public outdoor places. • The proportion of smoke-free substance use and psychiatric facilities is growing.

19. Smoke Free Programs and Campuses • Smoke-free hospitals are a model of success. • Helped patients. • Improved employee health, • Reduced employer costs, including health care costs. (Longo et al., 1996) • All patients should be given access to treatment for tobacco dependence to reduce withdrawal and promote quitting. Use of medications are particularly important for smokers with serious mental illness who have high levels of nicotine dependence. (Hagman et al., 2007; Williams et al., 2005)

20. Tobacco Control Goals Merge MI/SUD Tobacco Integration Programs

21. Bringing EveryoneAlong Faculty Douglas M. Ziedonis, MD, MPH Professor and Chair, Department of Psychiatry University of Massachusetts Medical School Boston, MA Gary J. Tedeschi PhD Clinical Director California Smokers’ Helpline University of California, San Diego Connie Revell Deputy Director Smoking Cessation Leadership Center University of California, San Francisco Eric Heiligenstein, MD Clinical Director, Psychiatry University Health Services University of Wisconsin-Madison Karen Siener, MPH Project Officer, Program Services Branch Centers for Disease Control and Prevention, Office on Smoking and Health Atlanta, GA Janet Smeltz, Med, LADC-I, M-CTTS Director, TAPE Project Institute for Health and Recovery Cambridge MA Chad Morris, PhD Associate Professor Director, Behavioral Health & Wellness Program University of Colorado, Denver, Department of Psychiatry Denver, Colorado

22. “The most important barrier to addressing tobacco use among vulnerable populations is the false belief that our patients/clients cannot or will not quit, rather than looking at how we can help them do so.” • Conclusion from the BEA Project

23. Fact #1 • Smokers who are homeless, or have mental illness (MI), or substance use disorders (SUD) want to quit and want information on cessation services and resources. • 79% diagnosed with depression were interested in quitting (Prochaska et al, 2004) • 50% - 77% in substance abuse treatment programs were interested in quitting (Joseph et al,2004) • About 35% of homeless smokers were interested in quitting (Connor et al, 2002, Arnsten et al, 2004) Source: Bringing Everyone Along Project (2008)

24. Fact #2 Smokers who are homeless, have mental illness, or substance use disorders can successfully quit using tobacco. • Quit rates are less than the general population, but still significant. • In major depression- up to 38% (Lasser et al., 2000) • In schizophrenia -10-30% (Addington et. al.,1998; Baker et al., 2006) • In addictions recovery – up to 38% (Prochaska et al, 2004) • Among homeless – 16% (Shelly et al, 2009) Source: Bringing Everyone Along Project (2008)

25. Fact #3 Symptoms usually do not worsen following reduced smoking or abstinence and can improve. • No deterioration in symptoms or functioning following reduction or abstinence (Baker et. al, 2006; Kiley & Campbell, 2008) • Quitters showed significantly lower levels of affective distress at the last follow-up assessment. (Currie et al, 2008) • Smoking cessation during addictions treatment increased long term abstinence from alcohol and drugs by 25%. (Prochaska et al, 2004) Source: Bringing Everyone Along Project (2008)

26. Tobacco Integration Programs

27. Model State Programs Colorado Wisconsin New York Indiana

28. Steps for Integration Projects* • Partnerships between state and local agencies; • Start-up funding and resources • Surveys, data • Contracts and agreements • Strategic plan, goals and priorities • Advisory committees • Regulatory steps • Funding

29. Steps for Integration Projects* • Implementation activities • Education, communication, outreach • Training for leaders and staff • Separate training for prescribers • Easy access to medications • Reimbursement and sustainability • Evaluation and outcomes

30. Colorado Mental Health Disparities Project

31. Colorado: Mental Health Disparities Project • Partnership between Tobacco Control Program and University Department of Psychiatry. • Start-up funding from Tobacco Control Program. • Population based survey to identify scope of problem. • Strategic plan: advisory committee of members from the disparate communities.

32. Colorado: Mental Health Disparities Project • Education and communication: • Training for quitline counselors– improve capacity to handle calls from MI/SUD clients. • Quitline supplies patches • Toolkit for providers • Training for prescribers • Training program for leaders • Monthly peer-to-peer conference calls.

33. Colorado: Mental Health Disparities Project: Lessons • Start with survey data. Clearly shows problem, hard to ignore. • Budget enough funding for assessment and strategic planning to do well. • Establish an official focus, include in agency commitments and budgets. • Keep meeting schedule for disparity advisory committee. Need ongoing advice. • Build support across facilities and agencies.

34. New York StateTobacco Independence Project

35. New York OASAS Tobacco Independence Project • New York Office of Alcoholism and Substance Abuse Services (OASAS) enacted new regulation in 2008 to prohibit smoking in all treatment facilities. • Partnerships formed between OASAS, New York Tobacco Control Program, and Alcoholism and Substance Abuse Providers (ASAP). • Four years of strategic planning.

36. New York OASAS Tobacco Independence Project • Implementation • Five forums of leaders around state to discuss regulation and problems. • Two barriers: • Need training for all staff; not prepared. • Need access to free medications for all clients. • Request to New York Tobacco Control Program for $8 million for two years for training and medications. • 12-18 month preparation: education, training, website.

37. New York OASAS Tobacco Independence Project: Lessons • Top-level support and commitment are necessary. • Resistance is common, needs strong leadership. • Partnership with Tobacco Control necessary for resources and funding. • Year of training and technical support helped prepare center staff. • Need flexibility to make adjustments for different needs in centers.

38. Meet Karen Balsamico

39. Karen Balsamico Karen has struggled with schizophrenia her whole life. She has painful memories of having her children taken away and being homeless. She smoked to escape her memories. Schizophrenia Digest, Spring 2005 www.schizophreniadigest.com

40. Beth Lilliard and Karen Balsamico With help, Karen stuck to her plan for quitting and the benefits followed. “The voices started to decrease after I quit. Quitting gave me a certain confidence. I figured, “If I can quit cigarettes, one of the hardest addictions to quit, then maybe there’s something more to do with my life.’” Schizophrenia Digest, Spring 2005 www.schizophreniadigest.com

41. Portland skyline at night