INTEGRATING TOBACCO TREATMENT INTO ADDICTION SERVICES

1. INTEGRATING TOBACCO TREATMENT INTO ADDICTION SERVICES Mike DeVillaer Provincial Services, CAMH Department of Psychiatry & Behavioural Neurosciences, McMaster University Addictions Ontario Conference May 31 2011

2. Coordinating Team • Mike DeVillaer, Provincial Services, CAMH • Peter Selby, Addictions Program, CAMH • Barney Savage, Public Policy, CAMH • JF Crepault, Public Policy, CAMH • Norma Medulun, Addictions Ontario • Ian Stewart, Ontario Federation of Community Mental Health and Addiction Programs Survey Research Associate: Natalie MacLeod, CAMH Project Partner: ConnexOntario

3. Funding The CAN-ADAPTT Project Tobacco Control Programme Health Canada

4. Buy In ?

5. Economic Costs of Drug Problems in Ontario, 2002 = $14,300 million Rhem et. al. (2006) The Costs of Substance Abuse in Canada in 2002. Canadian Centre on Substance Abuse.

6. 1.3+ Million Alcohol-, Tobacco- & Illegal Drug-Related Hospital Days, Ontario 200217.8% of all hospital days Rehm J. et.al. (2006). The Costs of Substance Abuse in Canada, 2002.Canadian Centre on Substance Abuse.

7. Drug-related Deaths in Ontario (2002) All deaths = 82,234 Rehm J. et.al. (2006). The Costs of Substance Abuse in Canada, 2002.Canadian Centre on Substance Abuse.

8. Type of Drug-related Deaths in Ontario (2002) Drug-related deaths = 15,253 Rehm J. et.al. (2006). The Costs of Substance Abuse in Canada, 2002.Canadian Centre on Substance Abuse.

9. From the General Population to the Addiction Treatment Population • more addiction treatment clients die from tobacco-related disease than from all other causes combined (Hurt et al.,1996)

10. The Provocative Question Is Ontario’s addiction treatment system saving people from the perils of other drugs so they can die from their use of tobacco ?

11. Smoking Prevalence in Addiction Treatment US median across all studies: 76.3% • For any single year: • Lowest: 65.0% • Highest: 87.2% (J. Guydish, et. al., 2011) • Ontario DATIS (2009-10): 46.4%

12. High Demand • 2009-10: 22,775 clients identified tobacco as a problem substance (DATIS, 2010) • third highest, behind alcohol and cannabis

13. Problem Drugs Identified by People in Drug Treatment Programs in Ontario, 2009-10 CAMH: DATIS Database May 2010; n =104,954

14. Our clients know that tobacco is harming them, and they are telling us so

15. It Makes a Difference • Non-smoking clients in addiction treatment programs have better outcomes than those who continue to smoke (McCarthy et. al., 2002; Satre et. al.,2007) • when we help our clients quit smoking we improve their overall health • may also improve their outcomes for other drug problems

16. Nova Scotia, Canada • Ministry of Health-funded addiction treatment programs are mandated to provide tobacco treatment to those clients who want it

17. Ontario Addiction Treatment Policy Arena • Ontario Ministry of Health’s “Setting The Course: A Framework for Integrating Addiction Treatment Services In Ontario” (1999) did not include the words ‘tobacco’ or ‘smoking’ • 2010: MH&LTC released Report of the Minister’s Advisory Group on the 10-Year Mental Health and Addictions Strategy • the words tobacco & smoking do not appear • In contrast, alcohol has lots of mentions

18. Bottom Line • deaths • hospitalization • economic costs • treatment outcomes • health status • tobacco one of our biggest drug problems • maybe the biggest

19. Why not recognized ? • not as much highly visible behavioural or social disruption • no personal crises requiring urgent attention • serious physical harm occurs later in life • manifested in hidden settings of hospital wards & home confinement

20. The Necessary Questions • Do you smoke tobacco ? • Would you like some help to quit ? • At minimum, a referral…

21. An Integration Issue • integrating addictions & mental health • integrate treatment of all addictions ? • major theme in the Ministry’s proposed 10 year strategy • highlighted in letter of transmittal to the Minister • “We are recommending more integrated services that will make better use of existing skills and resources.”

22. So what do we do about it ? • CAMH Tobacco Policy Group 2008 Workgroup comprised of representatives from: • Addictions Ontario • CAMH • Ontario Federation of Community Mental Health & Addiction Programs • ConnexOntario

23. Field Consultation, March 2009 • Invitation sent to addiction providers in members of Addictions Ontario & Ontario Federation of Community Mental Health and Addiction Programs • 34 addiction service providers: front-line & mgt • Purpose: identify, for clients, counsellors & programs, the benefits, hurdles & solutions for integrating tobacco treatment • Participant feedback was very positive • Full report sent to all member agencies of AO & Federation & available at camh.net

24. Benefits for Clients

25. Clients

26. Benefits for Counsellors

27. Counsellors

28. Benefits for Programs

29. Programs

30. Survey the Field Two Questions: 1) Provide tobacco treatment ? (yes/no) 2) If no, what are the barriers ? Option: comments

31. Survey Distribution • email to members of AO & OFCMHAP • 183 organizations operating 1395 programs • emailed again 10 days later • phone call to non-responders a week later • all organizations were phoned 2 or 3 times • CAMH’s Provincial Services followed up with some non-respondents in their respective communities • Survey closed May 2010 • Full & summary reports: camh.net

32. Results: Response Rate • 1130 programs run by 132 organizations responded • 81.0% of programs • 72.1% of organizations

33. Results: Prevalence of Tobacco Treatment in Addiction Services • tobacco treatment provided by 266 programs operated by 31 organizations • 23.5% of programs • 23.5% of organizations

34. Results: Barriers Organized by 3 implementation strategies: 1) Increase Awareness (18.0 % of barriers) • not important to clients • clients need smoking to cope with problems • not as important as other issues • jeopardize other treatment goals • too dramatic of a change for program’s culture • increase program wait times

35. Results: Barriers (cont’d) 2) Mandate Renewal (28.6 % of barriers) • no formal mandate from funder (MoH&LTC) 3) Resources (53.2% of barriers) • staff training • stop-smoking medication • adequate staffing levels

36. So, where are we ? • Big problem • No easy solution • Give up ?

37. “When I read about the evils of drinking, I gave up reading.” Henny Youngman

38. Why Are Alcohol & Tobacco Our Biggest Problems? • legal • aggressively & seductively marketed to people • not just allowed, but encouraged

40. Lifestyle Ads • 2 ads • 2 brands • 2 types of men • 2 market segments

41. Dakota: R.J. Reynolds Tobacco Company, 1990 • marketing campaign for a new cigarette brand • targeted young, poorly educated, white women • "virile females" • leaked to the Washington Post

42. Details in Leaked Document • target: women with no education beyond high school • women whose favourite pastimes included "cruising", "partying", attending "Hot Rod shows", & "tractor pulls" with their boyfriends • favourite television roles are "evening soap opera bitches“ • spend her free time "with her boyfriend doing whatever he is doing“ • chief aspiration is "to get married in her early twenties"

43. Common Themes in Tobacco Advertising 1) athletics: athletic male wearing a basketball jersey and baseball cap 2) nicotine as appetite suppressant • a woman who might wish to lose some weight • large confection suggests dieting may not be working • "lights", low calorie food products 3) romance: 'sweetheart' suggests that there may be a romantic encounter looming

44. MarketUptake ? Tobacco Control, Summer 1998: • prior to the start of the Joe Camel campaign, Camel’s share of the youth market (ages 12-17) was less than 1% • year and a half later, it had risen to 8% • by 1993, had climbed to 13%. U.S. Centre for Disease Control, October, 1998: • 73% increase in the number of American teens who became daily smokers since the debut of the Joe Camel ad campaign in 1988

45. Marketing Memorandum, stamped "RJR Secret", 1997 • "To ensure increased and longer term growth of Camel Filter, the brand must increase its share of penetration among the 14-24 age group which have a new set of liberal values and which represent tomorrow's cigarette business."

46. But publicly… • R.J. Reynolds 1994 statement: “…that smoking is a choice for adults and that marketing programs are directed at those above the age to smoke."

47. Markets & Clients • Just as a market has segments – • So does the population of tobacco smokers • They are not all the same • Many of those who continue to smoke may be very different from those who have quit

48. Public Health Tobacco Strategy • The strategies that have brought us unprecedented declines in smoking rates may not be the same strategies that will appeal to those who continue to smoke • We will need new strategies

49. Tobacco Industry What strategies do we use to make sure that current smokers do not join the majority of non-smokers ? • As before, they will focus on the vulnerable – your clients • 3-4 x more likely to smoke than the general population

50. Tobacco Industry & Vulnerable Market Segments • not social needs but personal psychological needs: • stress relief • behavioral arousal • performance enhancement • obesity reduction (Le Cook et. al, 2003)