TREATING TOBACCO DEPENDENCE in SMOKERS with CO-OCCURRING SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS:...
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TREATING TOBACCO DEPENDENCE in SMOKERS with CO-OCCURRING SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW. Judith J. Prochaska, PhD, MPH University of California, San Francisco. RATES of TOBACCO USE.

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TREATING TOBACCO DEPENDENCE in SMOKERS with CO-OCCURRING SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW

Judith J. Prochaska, PhD, MPH

University of California, San Francisco


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RATES of TOBACCO USE SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW

  • Smoking rate among individuals with mental illness is 2 to 4 x’s that of the general population (Hughes, 1993; Poirier, 2002)

    • As many as 74% to 88% of individuals with addictive disorders smoke (Kalman, 1998), compared to 23% in the general population (CDC, 2002)

  • Account for 44% to 46% of cigarettes sold in the US (Lasser et al., 2000; Grant et al., 2004)

175 billion cigarettes

$39 billion in annual sales


Trajectories of use l.jpg
TRAJECTORIES OF USE SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW

  • Earlier initiation of smoking

  • Heavier smoking

  • Greater nicotine dependence

  • Greater difficulty with quitting

  • Greater psychiatric, cognitive, & medical comorbidities

    • (e.g., Breslau et al., 1996; Burling et al., 1997; Novy et al., 2001; Richter et al., 2002; Saxon et al., 2003)


Trends in us adult smoking 1955 2004 l.jpg
TRENDS in US ADULT SMOKING: SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW1955–2004

Trends in cigarette smoking among persons aged 18 or older

20.9% of adults are current smokers

Male

Percent

Female

22.9%

17.5%

Graph provided by the Centers for Disease Control and Prevention. 1955 Current Population Survey; 1965–2004 NHIS. Estimates since 1992 include some-day smoking.


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SMOKING by DIAGNOSIS SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW

41.0% Overall

National Comorbidity Survey 1991-1992

Source: Lasser et al., 2000 JAMA

Active


Smoking in california l.jpg
SMOKING in CALIFORNIA SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW

Acton, Prochaska, Kaplan, Small & Hall. (2001) Addict Behav

Prochaska, Gill, & Hall. (2004) Psychiatric Services


Tobacco kills l.jpg
TOBACCO KILLS SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW

  • Individuals with mental illness die, on average, 25 years prematurely (Colton & Manderscheid, 2006)

    • elevated risk for respiratory and cardiovascular diseases and cancer, compared to age-matched controls(Brown et al., 2000; Bruce et al., 1994; Dalton et al., 2002; Himelhoch et al., 2004; Lichtermann et al., 2001; Sokal, 2004).

  • Current tobacco use is predictive of future suicidal behavior, independent of depressive symptoms, prior suicidal acts, and other substance use(Breslau et al., 2005; Oquendo et al., 2004, Potkin et al., 2003).


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TOBACCO & OTHER DRUG USE SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW

  • Half of all deaths among individuals treated for alcohol dependence were tobacco-related (Hurt et al., 1996)

  • Death rate 4 times greater among long-term drug abusers who smoke cigarettes vs. those who do not (Hser et al., 1994)

  • Synergistic health consequences of tobacco and other drug use: 50% greater than the sum of each individually (Bien & Burge, 1990)


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COMPARATIVE CAUSES of ANNUAL DEATHS in the UNITED STATES SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW

Individuals with mental illness or substance use disorders

Number of Deaths (thousands)

AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking

Vehicle Induced

Source: CDC


Health risks associated with chronic tobacco use l.jpg

Cardiovascular disease SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW

Lung Disease

Cancers

Delayed healing & recovery after surgery

Dyslipidemia

Hypertension

Macular degeneration

Cataract

Osteoporosis

Periodontal disease

Sexual dysfunction

Reduced fertility in women

Poor pregnancy outcomes

SIDS, child asthma

Mental Illness

HEALTH RISKS ASSOCIATED with CHRONIC TOBACCO USE


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COMPOUNDS in TOBACCO SMOKE SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW

An estimated 4,800 compounds in tobacco smoke

Gases (~500 isolated)

Particles (~3,500 isolated)

  • Carbon monoxide

  • Hydrogen cyanide

  • Ammonia

  • Benzene

  • Formaldehyde

  • Nicotine

  • Nitrosamines

  • Lead

  • Cadmium

  • Polonium-210

  • Arsenic

11 proven human carcinogens


Light cigarettes l.jpg
“LIGHT” CIGARETTES SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW

The difference between Marlboro and Marlboro Lights…

  • There are no true health benefits to light cigarettes.

  • Smokers compensate by either smoking more intensely (deeper inhalation) or by obstructing the vents.

an extra row of ventilation holes

Image courtesy of Mayo Clinic Nicotine Dependence Center - Research Program / Dr. Richard D. Hurt

The Marlboro and Marlboro Lights logos are registered trademarks of Philip Morris USA.


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“NO SAFE” LEVEL of SMOKING SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW

  • Smoking even 1 to 4 cigarettes a day nearly triples the risk of death from heart disease

  • Smokers who consume fewer cigarettes can reduce their risk of lung cancer, but still face a much larger risk of premature death or disability compared with people who quit

Source: Godtfredsen et al. (2005) JAMA, Bjartveit et al. (2005) Tobacco Control


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QUITTING: HEALTH BENEFITS SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW

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


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YEARS of SURVIVAL GAINED RELATIVE to CONTINUED SMOKING SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW

Source: DH Taylor et al., 2002 American Journal of Public Health


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WHY ADDRESS TOBACCO USE in PSYCHIATRIC POPULATIONS? SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW

Prevent Death

Improve Health

Optimize Psychiatric Medication Effects

Reduce Isolation

Patient $ Savings

Tobacco Industry Profits

Interest groups/politicians supported by Tobacco Industry

Tax revenues


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WHY do INDIVIDUALS with MENTAL ILLNESS SMOKE? SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW

Smoking in adolescence is associated with psychiatric disorders in adulthood, including: panic disorder, GAD and agoraphobia, depression and suicidal behavior, substance use disorders, and schizophrenia (Breslau et al., 2004; Weiser et al., 2004; Goodman, 2000; Johnson et al., 2000)

MENTAL ILLNESS

SMOKING

Active psychiatric disorders are associated with daily smoking and progression to nicotine dependence (Breslau et al., 2004).


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FACTORS ASSOCIATED with TOBACCO USE in those with MENTAL ILLNESS

Biologic & Pharmacologic

Genetic predisposition

Alleviation of withdrawal

Pleasure effects

Weight control

Psychological/Behavioral

Conditioning effects

Coping tool

Social interactions

Boredom

Tobacco Use

Systemic & Treatment

Use of cigarettes for reinforcement

Tobacco industry marketing efforts

Failure to treat in psychiatry & addiction treatment settings


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Dopamine ILLNESS

Norepinephrine

Acetylcholine

Glutamate

-Endorphin

GABA

Serotonin

NEUROCHEMICAL and RELATED EFFECTS of NICOTINE

N

I

C

O

T

I

N

E

 Pleasure, reward

 Arousal, appetite suppression

 Arousal, cognitive enhancement

 Learning, memory enhancement

 Reduction of anxiety and tension

Reduction of anxiety and tension

 Mood modulation, appetite suppr.

Benowitz.Nicotine & Tobacco Research 1999;1(suppl):S159–S163.


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DOPAMINE REWARD PATHWAY ILLNESS

Prefrontal cortex

Dopamine release

Stimulation of nicotine receptors

Nucleus accumbens

Ventral tegmental area

Nicotine enters brain

Amygdala


Chronic administration of nicotine effects on the brain l.jpg

Human smokers have increased nicotine receptors in the prefrontal cortex.

High

Low

Nonsmoker

Smoker

CHRONIC ADMINISTRATION of NICOTINE: EFFECTS on the BRAIN

Image courtesy of George Washington University / Dr. David C. Perry

Perry et al. J Pharmacol Exp Ther 1999;289:1545–1552.


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GENETIC EFFECTS on NICOTINE METABOLISM prefrontal cortex.

4.4%

0.4%

9.8%

Nornicotine

Nicotine-1'-

N-oxide

Nicotine

Nicotine

Nicotine

glucuronide

CYP2A6

Aldehyde oxidase

4.2%

~80%

Trans-3'-

hydroxycotinine

Trans-3'-

hydroxycotinine

Cotinine

Cotinine

13.0%

33.6%

Trans-3'-

hydroxycotinine

glucuronide

Cotinine

glucuronide

12.6%

Norcotinine

7.4%

Cotinine-

N-oxide

2.0%

Reprinted with permission, Benowitz et al., 1994.

2.4%




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NICOTINE ADDICTION CYCLE prefrontal cortex.

Reprinted with permission. Benowitz. Med Clin N Am 1992;2:415–437.


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NICOTINE WITHDRAWAL EFFECTS prefrontal cortex.

  • Dysphoric or depressed mood

  • Insomnia and fatigue

  • Irritability/frustration/anger

  • Anxiety or nervousness

  • Difficulty concentrating

  • Impaired task performance

  • Increased appetite/weight gain

  • Restlessness and impatience

  • Cravings*

Most symptoms peak 24–48 hr after quitting and subside within 2–4 weeks.

American Psychiatric Association. (1994). DSM-IV.

Hughes et al. (1991). Arch Gen Psychiatry 48:52–59.

Hughes & Hatsukami. (1998). Tob Control 7:92–93.

* Not considered a withdrawal symptom by DSM-IV criteria.


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WHAT is ADDICTION? prefrontal cortex.

“Compulsive drug use, without medical purpose, in the face of negative consequences”

Alan I. Leshner, Ph.D.

Former Director, National Institute on Drug Abuse

National Institutes of Health


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SYSTEMIC and TREATMENT FACTORS prefrontal cortex.


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PSYCHIATRISTS in PRACTICE prefrontal cortex.(Himelhoch & Daumit, 2003)

  • 1992-96 Nat’l Ambulatory Medical Care Survey

  • 23% of psychiatric visits dropped from analysis because patient smoking status unknown

  • For patients identified as smokers (N=1610)

    • Cessation counseling offered at 12% of visits

    • Nicotine Dependence not diagnosed at any visit

    • NRT never prescribed


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PSYCHIATRY RESIDENTS’ (N=105) ENGAGEMENT in the 5-As prefrontal cortex.

Nationally, only 50% of Adult Psychiatry Residency Programs provide training in treating nicotine dependence. Training duration is a median of 1-hour (Prochaska et al., 2006).

Source: Prochaska, Fromont et al., 2005 Acad Psychiatry


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ATTENTION to TOBACCO USE in ADDICTION TREATMENT prefrontal cortex.

  • Absent from most addictions treatment settings

  • 223 addiction treatment programs in Canada:

    • 10% offered formal smoking cessation programs

    • 54% reported placing very little emphasis on smoking

    • 47% still allowed smoking indoors (Currie et al., 2003).

  • Reluctance to encourage smoking cessation for fear that sobriety may be compromised


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BARRIERS to TREATING TOBACCO prefrontal cortex.

  • Smoking not viewed as a clinical issue

  • Our clients aren’t interested in quitting

  • Our clients can’t quit

  • Our clients need to smoke to manage their psychiatric symptoms and/or sobriety

  • Lack of training among providers

  • Not enough time, money…


Barriers to treating tobacco33 l.jpg
BARRIERS to TREATING TOBACCO prefrontal cortex.

  • Smoking not viewed as a clinical issue

  • Our clients aren’t interested in quitting

  • Our clients can’t quit

  • Our clients need to smoke to manage their psychiatric symptoms and/or sobriety

  • Lack of training among providers

  • Not enough time, money…


Smoking in psychiatry l.jpg

Pub. 1951 prefrontal cortex.

SMOKING in PSYCHIATRY


Tobacco documents l.jpg
Tobacco Documents prefrontal cortex.

Department of Health, Education, and Welfare

National Institute of Mental Health

Washington, DC

August 4, 1980

I am writing to request a donation of cigarettes for long-term psychiatric patients…because of recent changes in the DHHS regulations, Saint Elizabeth Hospital can no longer purchase cigarettes for them.

I am therefore requesting a donation of approximately 5,000 cigarettes a week (8 per day for each of the 100 patients without funds).


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JCAHO DECISION prefrontal cortex.

JCAHO ultimately “yielded to massive pressure from mental patients and their families, relaxing a policy that called on hospitals to ban smoking.”

An exception was made to allow continued smoking in psychiatric inpatient and substance use facilities for long-term patients.


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LD 463 - An Act to Exempt Substance Abuse and Psychiatric Patients from the Prohibition against Smoking in Hospitals


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DSM-IV TOBACCO USE DISORDERS Patients from the Prohibition against Smoking in Hospitals

Nicotine Dependence

  • Maladaptive pattern of use with significant impairment manifested by 3+ in 12-months:

    • Tolerance

    • Withdrawal

    •  Use

    • Unsuccessful efforts to stop

    • Time investment

    • Loss of important activities

    • Continued use despite knowledge of physical or psychological problems

Nicotine Withdrawal

  • Daily use of nicotine

  • Abrupt cessation/reduction followed within 24 hrs by 4+:

    • Depressed mood

    • Insomnia

    • Irritability

    • Anxiety

    • Difficulty concentrating

    • Decreased HR

    • Increased appetite

  • Clinically significant impairment

  • Not due to GMC

The majority of smokers with mental illness meet criteria for DSM-IV nicotine dependence and withdrawal (Prochaska et al., 2004; 2006)


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TOBACCO IMPACTS TREATMENT Patients from the Prohibition against Smoking in Hospitals

* Significant group difference in rates of against medical advice (AMA) hospital discharge (χ2 = 6.79, df = 2, p = .034), even after controlling for group differences.

Prochaska, Gill, & Hall. (2004) Psychiatric Services


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Caffeine Patients from the Prohibition against Smoking in Hospitals

Clozapine (Clozaril™)

Fluvoxamine (Luvox™)

Haloperidol (Haldol™)

Olanzapine (Zyprexa™)

Phenothiazines (Thorazine, Trilafon, Prolixin, etc.)

Propanolol

Tertiary TCAs / cyclobenzaprine (Flexaril™)

Thiothixene (Navane™)

Other medications: estradiol, mexiletene, naproxen, phenacetin, riluzole, ropinirole, tacrine, theophyline, verapamil, r-warfarin (less active), zolmitriptan

PHARMACOKINETIC DRUG INTERACTIONS of SMOKING

Drugs that may have a decreased effect due to induction of CYP1A2:

(Zevin & Benowitz, 1999)

Smoking cessation may reverse the effect.


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WHY MENTAL HEALTH and ADDICTION TREATMENT PROVIDERS? Patients from the Prohibition against Smoking in Hospitals

  • Often the clinician for whom contact is the most frequent and who knows the patient best

  • Able to combine psychopharmacological and behavioral/counseling treatment

  • Trained in substance abuse treatment

  • Able to identify and address any changes in mental health or other substance use during the quit attempt


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BARRIERS to TREATING TOBACCO Patients from the Prohibition against Smoking in Hospitals

  • Smoking not viewed as a clinical issue

  • Our clients aren’t interested in quitting

  • Our clients can’t quit

  • Our clients need to smoke to manage their psychiatric symptoms and/or sobriety

  • Lack of training among providers

  • Not enough time, money…


Studies of psychiatric patients readiness to quit l.jpg

* No relationship between psychiatric symptom severity and readiness to quit

STUDIES of PSYCHIATRIC PATIENTS’ READINESS to QUIT*

Smokers with mental illness are just as ready to quit smoking as the general population of smokers.


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INTEREST in TREATMENT readiness to quit

  • Stage-based tobacco treatment study in inpatient psychiatry – recruiting 82% of eligible smokers (Prochaska et al., in process)

  • Stage-based tobacco treatment study with depressed smokers – 32% entered Cessation Treatment component (Haug et al., 2005)


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TIMING of TOBACCO TREATMENT readiness to quit

  • 44 - 80% of individuals in addictions treatment report interest in quitting their tobacco use

  • 17 - 41% report concern that quitting during addictions treatment may make it harder to stay sober(Asher et al., 2003; Irving et al., 1994; Stein & Anderson, 2003)

  • Questions of when and how best to intervene


Barriers to treating tobacco48 l.jpg
BARRIERS to TREATING TOBACCO readiness to quit

  • Smoking not viewed as a clinical issue

  • Our clients aren’t interested in quitting

  • Our clients can’t quit

  • Our clients need to smoke to manage their psychiatric symptoms and/or sobriety

  • Lack of training among providers

  • Not enough time, money…


Treatment of depressed psychiatric outpatients for cigarette smoking l.jpg

Sharon Hall, PhD, Janice Tsoh, PhD, Judith Prochaska, PhD, MPH, Stuart Eisendrath, MD, Joseph Rossi, PhD, Colleen Redding, PhD,

Amy Rosen, PsyD, Marc Meisner, MD, Gary Humfleet, PhD, & Julie Gorecki, MA

University of California, San Francisco

Supported by NIDA #P50 DA09253

Am J Public Health 2006

TREATMENT of DEPRESSED PSYCHIATRIC OUTPATIENTS for CIGARETTE SMOKING


Study design l.jpg
STUDY DESIGN MPH, Stuart Eisendrath, MD, Joseph Rossi, PhD, Colleen Redding, PhD,

  • 322 depressed smokers recruited from four outpatient psychiatry clinics

  • Stepped Care Intervention

    • Stage-based expert system counseling

    • Nicotine patch

    • 6 session individual CBT counseling

    • Bupropion available

  • Brief Contact Control

  • Primary outcome:

    • 7 day PPA @ 12 & 18 months, CO verified


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ABSTINENCE RATES by TREATMENT CONDITION MPH, Stuart Eisendrath, MD, Joseph Rossi, PhD, Colleen Redding, PhD,

*

*

* p<.05 for group comparison


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MENTAL HEALTH OUTCOMES MPH, Stuart Eisendrath, MD, Joseph Rossi, PhD, Colleen Redding, PhD,

  • Among depressed smokers who quit:

    • No increase in suicidality

      • Quit: 0% vs Smoking: 1-4%

    • No increase in psych hospitalization

      • Quit: 0-1% vs. Smoking: 2-3%

    • Comparable improvements in BDI and STAXI scores and % of days with emotional problems

Prochaska et al., in press, Am J Public Health


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BDI TOTAL SCORE MPH, Stuart Eisendrath, MD, Joseph Rossi, PhD, Colleen Redding, PhD,

Moderate

Mild

Minimal


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TREATING DEPRESSED SMOKERS MPH, Stuart Eisendrath, MD, Joseph Rossi, PhD, Colleen Redding, PhD,

  • Stage-based tobacco treatment with CBT and NRT significant effects at 12 and 18 months

  • No evidence of worsened psychiatric symptoms associated with quitting smoking

  • Smoking can be treated concurrent with depression without adverse effects to mental health functioning


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Judith Prochaska, PhD, MPH MPH, Stuart Eisendrath, MD, Joseph Rossi, PhD, Colleen Redding, PhD,

Kevin Delucchi, PhD & Sharon Hall, PhD

University of California, San Francisco

Supported by TRDRP #11FT-0013and NIDA #P50 DA09253

JCCP 2004

Journal of Consulting and Clinical Psychology, 2004

A META-ANALYSIS of SMOKING CESSATION INTERVENTIONS with INDIVIDUALS in SUBSTANCE ABUSE TREATMENT or RECOVERY


Study purpose l.jpg
STUDY PURPOSE MPH, Stuart Eisendrath, MD, Joseph Rossi, PhD, Colleen Redding, PhD,

  • To assess, in a meta-analysis, the effectiveness of smoking cessation interventions evaluated with individuals in substance abuse treatment or recovery

  • To compare outcomes for those in treatment versus recovery to provide some guidance on the optimal timing of smoking cessation interventions in relation to addictions treatment


Method l.jpg
METHOD MPH, Stuart Eisendrath, MD, Joseph Rossi, PhD, Colleen Redding, PhD,

  • Computer-based and manual search of the research literature (1966-2003)

    • MEDLINE, PsychINFO, EMBASE, ECO, Biosis, Cochrane Library, Digital Dissertations, Conference Abstracts (SRNT)

  • Study inclusion criteria:

    • Randomized controlled design

    • Evaluation of a smoking cessation intervention

    • Subjects in addictions treatment or recovery

    • Adult aged sample (> 18 years old)

    • Quantitative assessment of smoking cessation (e.g., point prevalence abstinence)


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SEARCH RESULTS MPH, Stuart Eisendrath, MD, Joseph Rossi, PhD, Colleen Redding, PhD,

MEDLINE 53 citations

18 studies met criteria

13 unique publications

PsychINFO / Biosis 0

ECO 1 additional

Digital Dissertations 1 additional

Conference abstracts 1 additional

Manual biblio search 3 additional

Total 19 studies (1991-2003)

In Treatment 12 studies (N=1410)

In Recovery 7 studies (N=638)


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DATA EXTRACTION MPH, Stuart Eisendrath, MD, Joseph Rossi, PhD, Colleen Redding, PhD,

  • Studies independently reviewed by two reviewers

    • One blinded to authors, institution, journal, title, pub year, refs

  • Abstinence rates at post-treatment and longest follow up (i.e., 6- to 12-months) abstracted

    • Most conservative estimates used (i.e., biochem verified, ITT)

  • PPA, reported in 15 studies, used as smoking outcome

  • For drug/alcohol outcomes, any use counted as relapse to be conservative and for consistency across studies

  • Lead authors contacted to provide additional information when necessary


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DESCRIPTION of STUDIES MPH, Stuart Eisendrath, MD, Joseph Rossi, PhD, Colleen Redding, PhD,

  • Sample sizes: 22 – 575 (Mdn = 63)

  • Settings:

    • 7 residential (e.g., VA residential, psychiatric dual diagnosis, perinatal drug abuse tx program)

    • 12 outpatient (e.g., methadone clinics, primary care, university)

All comparisons p<.001


Interventions l.jpg

Psychosocial: MPH, Stuart Eisendrath, MD, Joseph Rossi, PhD, Colleen Redding, PhD,

Brief advice/educational = 4

Skill training/behavioral = 6

CBT = 4

Stage-based/motivational = 4

Nicotine anonymous = 1

Generalization to sobriety = 6

Pharmacological:

NRT = 11

Bupropion = 1

Fluoxetine = 1

Methadone = 1

INTERVENTIONS

Number of contacts: 1 – 36 M = 12

Session contact length: 5 min – 2 hrs M = 42 min

Intervention duration: 1 day – 1+ yr M = 13 wks

Total contact: 15 min – 24 hrs M = 8.3 hrs


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ANALYSES MPH, Stuart Eisendrath, MD, Joseph Rossi, PhD, Colleen Redding, PhD,

  • Abstinence status by condition recorded in 2x2 tables using Comprehensive Meta-Analysis(Biostat, Englewood, NJ)

  • Abstinence rates expressed as relative risks (RRs) with 95% confidence intervals (CIs)(Fleiss, 1993)

    • RR >1.00 favors intervention for increased abstinence relative to control

  • Effects calculated for smoking and substance use at post-tx and longest FU (6- to 12-mos). Multiple intervention groups collapsed and compared to control group.

  • Random-effects models, incorporating variance between study findings in a weighted average of rate ratios, used to estimate overall RR and 95% CI(DerSimonian & Laird, 1986).

  • Heterogeneity of pooled results, p < .10 considered significant(Oxman et al., 1994).


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Post-Treatment Smoking Outcomes MPH, Stuart Eisendrath, MD, Joseph Rossi, PhD, Colleen Redding, PhD,



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OVERALL SMOKING for In-Treatment StudiesCESSATION RATES

Post–Treatment Long-term FU

18 studies

15 studies



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CONCLUSIONS TREATMENT

  • Significant treatment effects for quitting smoking at post-treatment, but not at long-term follow up (>6 months)

  • At long-term follow up, evidence of improvedsobriety among intervention participants

    • 25% greater odds of being sober if exposed to the tobacco cessation intervention


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CONCLUSIONS TREATMENT

  • Contrary to previous concerns, smoking cessation efforts delivered during addictions treatment appeared to enhance, rather than compromise, long-term sobriety

  • Potential mechanisms may relate to:

    • extended intervention contact time

    • reduced cues to substance use

    • practice with relapse prevention skills

    • increased sense of mastery

    • positive overall change in lifestyle


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BARRIERS to TREATING TOBACCO TREATMENT

  • Smoking not viewed as a clinical issue

  • Our clients aren’t interested in quitting

  • Our clients can’t quit

  • Our clients need to smoke to manage their psychiatric symptoms and/or sobriety

  • Lack of training among providers

  • Not enough time, money…


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PSYCHIATRY RESIDENTS’ (N=105) TRAINING in TOBACCO TREATMENTS

Prochaska et al., 2005 Acad Psychiatry


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INTEREST in FURTHER TRAINING TREATMENTS

Prochaska et al., 2005 Acad Psychiatry


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NATIONAL SURVEY of PSYCHIATRY RESIDENCY TRAINING DIRECTORS TREATMENTS

  • 114 respondents (63% response rate)

  • 50% of programs provide tobacco training

  • Median of 1 hr duration

  • Lack of faculty expertise a barrier to providing training

  • 89% interested in evaluating a model tobacco cessation training curriculum

    • Would dedicate 4 hrs to the training

Prochaska et al., 2006 Acad Psychiatry


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DEVELOPMENT and EVALUATION of a TOBACCO TREATMENT CURRICULUM for PSYCHIATRY RESIDENCY TRAINING PROGRAMS

  • 4-hr evidence-based tobacco treatment curriculum

  • 3 adult psychiatry residency training programs in Northern California

  • 56 residents (75% participation)

  • Measures of knowledge, attitudes, confidence, and behaviors at baseline, post-training, and 3 mo follow up

  • 6-mo chart review at one of the sites (N=1204 charts)

Prochaska et al., in press Acad Psychiatry

Funded by California TRDPR (#13KT-0152)


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RESULTS: Knowledge for PSYCHIATRY RESIDENCY TRAINING PROGRAMS

  • Gains in knowledge scores significant from pre- to post-training, averaging +17 percentage points,

    • t51= 7.32, p<.001

  • Significantly associated with attendance

Fig 1. Knowledge Gains (Pre- to Post-Training), by Attendance


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RESULTS: Attitudes for PSYCHIATRY RESIDENCY TRAINING PROGRAMS

Change in Residents’ Perceived Barriers to Treating Tobacco Dependence in Psychiatry

High

Barriers Scale, 10-items Cronbach alpha=0.83

Pre-training vs. post-training

* t51 = 5.36, p< 0.001

Pre-training vs. 3-month FU

** t35= 4.56, p<0.001

*

**

Low


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RESULTS: Attitudes for PSYCHIATRY RESIDENCY TRAINING PROGRAMS

Ratings made on a 5-point scale: 1=strongly disagree to 5=strongly agree.

* p <.05 for paired sample t-test for time comparison, where T1 = pre-test, T2 = post-training, and T3 = 3 month follow-up


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RESULTS: Confidence for PSYCHIATRY RESIDENCY TRAINING PROGRAMS

Confidence Scale, 6-items Cronbach alpha=0.82

Pre-training vs. post-training

* t51 = 10.58, p< 0.001

Pre-training vs. 3-month FU

** t35= 8.60, p<0.001

Extremely

confident

*

**

Not at all confident


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RESULTS: Confidence for PSYCHIATRY RESIDENCY TRAINING PROGRAMS

All pre-post comparisons significant at p<.05


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RESULTS: Self-reported Behaviors for PSYCHIATRY RESIDENCY TRAINING PROGRAMS

* pre-training to 3-month follow up comparison significant at p<.05


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RESULTS: Charted Behaviors for PSYCHIATRY RESIDENCY TRAINING PROGRAMSBaseline to 3 month follow-up (N=1204 medical records)

* p<.05 for change from baseline to 3mo FU


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BARRIERS to TREATING TOBACCO for PSYCHIATRY RESIDENCY TRAINING PROGRAMS

  • Smoking not viewed as a clinical issue

  • Our clients aren’t interested in quitting

  • Our clients can’t quit

  • Our clients need to smoke to manage their psychiatric symptoms and/or sobriety

  • Lack of training among providers

  • Not enough time, money…


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MEDICARE / MEDI-CAL for PSYCHIATRY RESIDENCY TRAINING PROGRAMS

  • Medicare covers cessation counseling and pharmacotherapy (NRT, bupropion) for smokers with tobacco-related health conditions or drug interactions

  • Medi-Cal covers pharmacotherapy for smokers in a cessation program (includes toll-free quitlines)


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COMPARATIVE DAILY COSTS for PSYCHIATRY RESIDENCY TRAINING PROGRAMSof PHARMACOTHERAPY

$6.07

$5.88

$3.75 generic

$5.00 in CA

$4.00

$3.67

$3.48 (generic)

$2.84 (generic)

$2.62 (generic)

$1.13 (generic)

.91¢ (generic)

Cost per day, in U.S. dollars


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FINANCIAL IMPACT of SMOKING for PSYCHIATRY RESIDENCY TRAINING PROGRAMS

Buying cigarettes every day for 50 years @ $3.75/pack for generic or $5.25/pack for brand name. Money banked monthly, earning 5.5% interest

2

Packs

per

day

1.5

1


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ANNUAL SMOKING-ATTRIBUTABLE ECONOMIC COSTS for PSYCHIATRY RESIDENCY TRAINING PROGRAMS—U.S., 1995–2001

Prescription

drugs,

$6.4 billion

Other care,

$5.4 billion

Medical expenditures (1998)

Ambulatory care,

$27.2 billion

Hospital care,

$17.1 billion

Nursing home,

$19.4 billion

Societal costs:

$7.65 per pack

Annual lost productivity costs

(1997–2001)

Men,

$61.9 billion

Women,

$30.5 billion

Billions of dollars

CDC.MMWR 2002;51:300–303 and MMWR 2005;54:625-628.


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BARRIERS to TREATING TOBACCO for PSYCHIATRY RESIDENCY TRAINING PROGRAMS

  • Smoking IS a clinical issue relevant to mental health and substance abuse treatment

  • Our clients ARE interested in quitting

  • Our clients CAN quit WITHOUT threat to their mental health recovery or sobriety

  • Providers ARE INTERESTED in training and training programs IMPACT clinical practice

  • Tobacco treatment is COST-EFFECTIVE and can be done efficiently


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  • “Those who deliver mental health care often pride themselves on treating the whole patient, on seeing the big picture, and on not being bound by financial irrationality or by the biases of their culture; yet many fail to treat nicotine dependence. They forget that when their patient dies of a smoking-related disease, their patient has died of a psychiatric illness they failed to treat.”

    - John Hughes, 1997


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ACKNOWLEDGEMENTS themselves on treating the whole patient, on seeing the big picture, and on not being bound by financial irrationality or by the biases of their culture; yet many fail to treat nicotine dependence. They forget that when their patient dies of a smoking-related disease, their patient has died of a psychiatric illness they failed to treat.”

  • Sharon Hall, PhD, Sebastien Fromont, MD, Karen Hudmon, DrPH, RPh, Desiree Leek, BS

  • National Institute on Drug Abuse (#K23 DA018691, #P50 DA09253)

  • California Tobacco Related Disease Research Program (#13KT-0152)

  • American Cancer Society (IRG#AC-08-04)


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