Treating Tobacco dependence in mental health settings

TREATING TOBACCO DEPENDENCE IN MENTAL

HEALTH SETTINGSPRESENTED BY SARAH WORLEY

SYNOPSIS OF MATERIAL FROM RUTGERS

CONFERENCE

THE TRUTH

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REASONS TO TREAT TOBACCO USE

•Tobacco use kills half of our patients

•Tobacco use limits full recovery

•Tobacco use disorder is in the DSM

•Tobacco use has a negative impact on

treatment

WHY TREAT TOBACCO

DEPENDENCE IN MENTAL HEALTH

SETTINGS

• 51 million smokers in the US today

• At least 1/3 have a mental illness

• 3/4 of smokers have a past or present problem with mental illness or addiction

• Smoking is the #1 cause of death in people with mental illness or addiction

50% of deaths in schizophrenia, depression, and bipolar disorder are

attributed to tobacco• People with SMI die, on average, 25 years earlier than the general

population.

• The leading causes of death among those individuals are:

• Heart Disease

• Cancer

• Cerebrovascular

• Chronic Respiratory

• All of these causes are smoking related!

IT’S THE SMOKE THAT KILLS

• CIGARETTE SMOKE > 7000

COMPOUNDS

• >65 ARE CARCINOGENS WHICH

ARE KNOWN TO CAUSE CANCER

Some examples are:▪ Lead is a harmful metal,

capable of causing serious damage to the brain, kidneys, nervous system

and red blood cells.▪ Nickel causes increased susceptibility to lung

infections.▪ Formaldehyde causes respiratory and gastro-

intestinal problems.

ADDITIONAL REASONS TO TREAT TOBACCO DEPENDENCE

• Tobacco use may worsen behavioral health outcomes, while cessation

does not worsen outcomes.

• Daily smoking predicts suicidal thoughts or attempt.

• States with an increase in $1 in state excise tax per pack of cigarettes was associated

with a 12.4% reduction in risk of suicide.

• Smoking keeps consumers from achieving recovery:

• Being Financially Stable

• Getting Jobs

• Securing Housing

• Treating tobacco-dependence is cost-effective and save healthcare

dollars.

ADDITIONAL REASONS TO TREAT TOBACCO DEPENDENCE

• Treating tobacco dependence improves employee productivity and

health.

• Behavioral health practitioners have more time than primary care

providers for psychosocial treatments for tobacco dependence.

• Tobacco use interferes with psychiatric medication.

• Addressing tobacco use fits into the current wellness and recovery

movement.

• Addressing tobacco use during treatment of other substance use

disorders increased the likelihood of long-term abstinence from

alcohol and illicit drugs by 25%.

WHY DO SO MANY CONSUMERS WITH MENTAL ILLNESS SMOKE?

There is no easy answer as to why so many

people living with mental illness smoke.

Smoking is a complex problem made up of

biological, psychological and

social/environmental factors.

BIOLOGICAL FACTORS (PHYSICAL/ BRAIN FUNCTIONS)

• People living with a mental illness may be at

increased risk for physical addiction to smoking.

•Nicotine may help improve mood, or mental

functions like attention, memory or learning, in

some people diagnosed with mental illness.

PSYCHOLOGICAL FACTORS (THINKING/ FEELING)

•People diagnosed with a mental illness may

not feel confident that they can quit.

•People diagnosed with a mental illness may

rely on smoking to help them cope with

stress.

SOCIAL FACTORS (PEOPLE/ PLACES/ THINGS AROUND YOU)

•Smoking is common in and around mental

health hospitals, treatment centers and

group homes.

•People with a mental illness may feel like it

is easier to talk with others and be around

others when they are smoking.

UNDERSTANDING TOBACCO ADDICTION NEUROBIOLOGY

• Addiction is a developmental disease that starts in adolescence

and childhood.

• Possible biological factors include an increased genetic vulnerability, a

greater susceptibility to progressing from tobacco use to dependence,

because of a greater subjective experience of reward or pleasure, or that

tobacco/nicotine helps some of the symptoms related to a behavioral

disorder. Cigarette smoking may be an attempt to self-medicate symptoms

of depression, anxiety, boredom, loneliness, and other feelings common in

this population.

• Tobacco use in adolescents is highly correlated with other substance use

and usually precedes the onset of other substance-abuse and psychiatric

illness. There may be particular risks of progressing from tobacco use to

dependence for a subgroup of adolescents who are especially vulnerable to

mental illness and/or other addictions. Adolescents with multiple life and


• Gateway theory:

• High school seniors using cigarettes < age 13 had 3x risk of

using marijuana.

• Nicotine binds in the cortex, hippocampus, and reward

pathways.

• Dopamine release

• Arousal, enhanced vigilance

• Appetite suppression

• Mood changes


• Schizophrenia and tobacco

• Patients with schizophrenia smoke at nearly three times the rate of the

general population, with most studies finding prevalence rates of about 90%.

Cigarette smoking in schizophrenia may be especially reinforcing, as it may

improve psychiatric symptoms or cognitive functioning or prevent the

worsening of these symptoms during the withdrawal from nicotine.

Schizophrenics are often highly nicotine dependent and are hypothesized to

be efficient and effective smokers. Clinical observation reveals that

schizophrenics smoke nearly continuously during the day, and smoke

cigarette filters and discarded butts, which are highly concentrated with

nicotine. Some of these effects may be related to the use of antipsychotic

medications that block dopamine postsynaptic receptors. Schizophrenics

who smoke have lower rates of neuroleptic- induced Parkinsonism. Ad

libitum smoking in schizophrenics increases after initiation of haloperidol

relative to a baseline rates when free of antipsychotic medications.

Schizophrenics smoke less when treated with clozapine versus conventional


• Depression and tobacco

• Lifetime prevalence of depression is 5–12% in men and 12–20% in women, making it extremely common and projected to cause the second greatest disease burden in the world by the year 2020. Many studies link the effects of smoking to depression and vice versa because it is common for smokers to have symptoms of depression or develop them when they are trying to quit smoking. According to the Epidemiologic Catchment Area (ECA) survey, about 70% of men and 80% of women with a history of major depression have current or past smokers and 25–40% of psychiatric patients seeking smoking cessation treatment have a past history of major depression or minor dysthymic disorder. The presence of depressive symptoms during tobacco abstinence is associated with failed quit attempts, increased probability of returning to smoking and the need for more quit attempts. Women with depression experience greater difficulty in maintaining early abstinence than non-depressed women. Data from family, adoption, and twin studies strongly support a substantial genetic influence on the initiation and maintenance of smoking, and several studies suggest a genetic predisposition to both nicotine dependence and depression. Family studies reveal smoking patterns that differ according to the subtype of depressive disorder, with the closest association observed between dysthymia


• Attention-deficit hyperactivity disorder (ADHD) and tobacco

• Both children and adults with ADHD are significantly more likely to

smoke than non-ADHD controls. This association suggests that

people with ADHD use smoking to improve attention and cognitive

performance. Nicotine administered in a laboratory setting

significantly reduces the symptoms of ADHD, an effect seen in both

smokers and nonsmokers. Nicotine, like the psychostimulants

methylphenidate and dextroamphetamine, acts as an indirect

dopamine agonist, which is relevant to attentional processing within

the brain.


• Anxiety disorders and tobacco

• The presence of an anxiety disorder with or without concurrent depression is associated with an increased likelihood of smoking. Smoking has been found to be a risk factor for the onset of panic disorder and elevated smoking rates are observed in patients with panic disorder. Heavy smoking in adolescence is associated with a higher risk of panic disorder, generalized anxiety disorder, and agoraphobia, even after controlling for confounding variables, such as age, educational status, and parental smoking. Smoking can lead to panic attacks, but the reverse relationship is unlikely and not supported by research findings. Posttraumatic Stress Disorder (PTSD), is associated with rates of smoking around 60%. This is true for women as well as combat veterans with PTSD. Heavy smokers with PTSD are characterized by more total PTSD symptoms as well as increased Cluster C (avoidance and numbing) and Cluster D (hyperarousal) symptoms.

• Despite patients’ subjective reports that smoking reduces anxiety, chronic nicotine use in animal studies is related to increased anxiety. It is unclear to what extent smokers experience withdrawal symptoms and misinterpret a reduction in withdrawal as anxiety relief. Serotonergic interactions with nicotine in the brain seem to mediate at least some of these effects. Serotonin may play an important role in modulating the effects of nicotine, although details of the exact circuitry are still unknown. Areas of the cortex, hippocampus, and dorsal raphe nucleus involve stimulation of 5-HT(1A) receptors and warrant further research. Data from animal and human studies suggest that under certain conditions, nicotine can act as an anxiolytic and antidepressant, but that following chronic use, anxiety is increased.

PLEASE CONSIDER THE…

Challenges

• Tobacco use still causes more deaths

each year than does alcohol, heroin,

cocaine, HIV, homicides, suicides,

fires, and accidents combined

• One third to one half of all cigarettes

smoked in the US are smoked by

people who have had a mental illness

or substance use disorder

• Mental health professionals and

systems are addressing tobacco less

often than in other areas of

healthcare

Changes

• Old view…Quitting tobacco will make them worse.

• New view…Quitting tobacco is part of recovery from a mental illness or substance use disorder. Quitting tobacco won’t hinder progress and might even be beneficial in ways beyond health improvement.

• As administrators or treatment providers we may experience mixed feelings about addressing tobacco. On the one hand we desire and have hope for different situations or outcomes, while at the same time we can be fearful of rocking the boat or reluctant to leave our comfort zone. Addressing tobacco use along with your clients’ other conditions requires confronting old beliefs and ways of doing things as well as attitudes and views of people and what is possible. To be successful, this process of change must take place at multiple levels – with individuals, staff, and the organization. It is important to recognize that nationally, individual clinicians and behavioral health organizations are confronting these same issues, yet recognizing that addressing tobacco use is possible

NICOTINE WITHDRAWALThere is a general consensus that those who smoke at least 10 cigarettes per day,

or those who smoke within 60 minutes of waking, are moderately dependent, and

those who smoke at least 20 cigarettes per day, or within 30 minutes of waking

are highly nicotine dependent.

Withdrawal symptoms can mimic a number of mental health illness symptoms

such as:

• Dysphoric or depressed mood

• Insomnia

• Irritability, frustration, or anger

• Anxiety

• Difficulty concentrating

• Restlessness

• Decreased heart rate

• Increased appetite or weight gain

Withdrawal symptoms can last up to four weeks.

ASSESSMENTS USED TO ASSESS NICOTINE DEPENDENCE

•The Fagerstrom Test for Nicotine

Dependence

•The Hooked on Nicotine Checklist

NICOTINE DEPENDENCE ASSESSMENTS

OTHER FACTORS TO BE ASSESSED

•Patient Self-efficacy

•Environmental Factors and Social Support

•Patient Beliefs about Smoking and Quitting

TREATMENT OPTIONS

•Pharmacotherapy

•Psychosocial Therapy

•Psychotherapeutic Treatments

•Supportive Treatment

•Practical Counseling

PHARMACOLOGICAL THERAPY OPTIONS AND WHY

•HARD TO QUIT WITHOUT TREATMENT

• 70% of smokers report wanting to quit someday

• Few people quit successfully without treatment

• Only 1/3 of quitters (without treatment) remain abstinent

for 2 days

• < 5% ultimately successful on a given quit attempt

PHARMACOLOGICAL THERAPY OPTIONS AND WHY

•RATIONALE

•Doubles changes of successful quit

• Cost-effective

• Reduce or eliminate withdrawal

• Lessen/delay weight gain

• Block reinforcing effects of nicotine

PHARMACOLOGICAL THERAPY OPTIONS

FIRST-LINE TREATMENTS (FDA APPROVED)

•Nicotine Replacement Therapy

• Buproprion

• Zyban/Wellbutrin

• Varenicline

• Chantix

Counseling + Medications = Best treatment plan


• Nicotine Replacement

• Patch

• Gum

• Lozenge

• Inhaler

• Nasal Spray

• Bupropion

• Varenicline

Available OTC but may be covered with prescription state Medicaid.


NICOTINE MEDICATIONS

• Not a carcinogen

• Use high enough dose

• Scheduled better than PRN

• Use long enough time period

• Can be combined with bupropion

• Can be combined with each other

• Have almost no contraindications

• Have no drug-drug interactions

• Safe enough to be OTC


•Smokers misinformed about safety/efficacy

of nicotine

•Not a carcinogen

•Not a significant risk factor for cardiovascular

events

Risk-Benefit ratio supports nicotine

medications over using tobacco

PHARMACOLOGICAL THERAPY OPTIONSCOMBINATION THERAPIES

Improve abstinence rates

Decrease withdrawal

Well-tolerated

• Certain combinations of first-line medications have been shown to be effective smoking cessation

treatments. Effective combination medications are:

• Nicotine patch + nicotine gum or nicotine lozenge or nicotine nasal spray or nicotine inhaler

• Nicotine patch + bupropion SR

• Combining Varenicline with NRT agents is not recommended and may have higher rates of side

effects (e.g., nausea, headaches)

• Varenicline is a partial agonist (causes a little Dopamine release but not enough to be addictive)

• Partially stimulates receptor “Antagonist” –blocks nicotine binding

a4B2 (no good effects from nicotine are felt)

• Some DA release at NAcc

• Prevents Withdrawal


VARENICLINE AND NEUROPSYCHIATRIC SIDE EFFECTS

• Studies not sponsored by Pfizer

• Industry and non-industry funded studies

• NO increased risk of suicide

• NO increased risk of suicidal ideation

• NO increased risk of depression

• NO increased risk of irritability

• NO increased risk of aggression

• Increased risk of sleep disorders

• Increased risk of insomnia

• Increased risk of abnormal dreams

• Reduced risk of anxiety


BLACK BOX WARNINGS

• Antidepressants- suicidal ideation in children

• Lithium- toxicity

• Depakote- hepatic failure

• Lamictal- Toxic epidermal necrolysis

• Wellbutrin- serious allergy, seizure

• Antipsychotics- mortality elderly dementia-psychosis

PSYCHOSOCIAL THERAPY

•Motivational Interviewing

• Behavioral health providers have the required skill

set

• You already help your patients with:

• Problem-Solving

• Coping with difficult situations/emotions

• Social skills training

• Making better choices

• Avoiding high risk situations


•NO SCIENTIFIC EVIDENCE THE FOLLOWING

THERAPIES HELP PEOPLE QUIT SMOKING:

• Hypnosis

• Acupuncture

• Laser therapy (like acupuncture, but no needles)

• E-cigarettes

• Little evidence for e-cigarette efficacy

• Not demonstrated to be as safe as available FDA approved

treatments

• Not regulated by the FDA so chemicals can change per purchase

per producer


WHAT ABOUT THOSE NOT INTERESTED IN QUITTING?

• Build motivation for later

• MI: Decisional balance

• 5 A’s

• Ask about tobacco use

• Advise to quit

• Assess willingness

• Assist in quit attempt

• Arrange follow-up

• Discuss reduction-to-quit

• Use Learning About Healthy Living Manual

PSYCHOSOCIAL THERAPYLEARNING ABOUT HEALTHY LIVING MANUAL- A copy of the manual has been

added to the S:Drive Therapy

Workbook Folders

• Tailored specifically for those with serious mental illness to engage those

who are unmotivated to talk not only about quitting smoking but other

healthy living habits.

• Manual developed to help lower motivated smokers

• For mental health settings

• Group format

• Education on range of topics

• Healthy eating

• Increasing activity

PSYCHOTHERAPY TREATMENTS

•GROUP COUNSELING

• Cost/time effective

• Additional support

• Accepted treatment in Mental Health and addiction

treatment settings

• Modeling

+ Seeing success/use of cessation meds

+ Effective coping

+ May change treatment program norms

- Vocal/outgoing continuing smokers

PSYCHOTHERAPY TREATMENTS

• INDIVIDUAL COUNSELING

• Less time effective, but benefits from greater intensity

• Intervention components can be more personalized

• Facilitates therapeutic alliance

• Avoids shy/anxious/non-talkative patient falling

through cracks in a group

SUPPORTIVE TREATMENT• ENCOURAGE

• Demonstrate your belief your patient can quit

• Note all the available options

• Note that ½ of all smokers have been able to quit

• Note that you’ve helped others quit

• COMMUNICATE CARING/CONCERN

• “How do you feel about quitting?”

• “I’m here to help you.”

• “I know this is tough”

• TALK ABOUT THE QUITTING PROCESS

• Learn about why patient wants to quit

• Learn about previous successes

• Learn about previous difficulties (just enough to avoid them this time)

PRACTICAL COUNSELING• PROVIDE BASIC INFORMATION

• Addiction, not just a “habit”

• Withdrawal

• Meds

• RECOGNIZE HIGH-RISK SITUATIONS

• The treatment program

• Stress, other smokers, alcohol

• Smoking paraphernalia, availability of cigarettes

• DEVELOP COPING SKILLS

• Anticipate and avoid temptations & triggers

• Cognitive and behavioral strategies for:

• Reducing stress/negative affect

• Coping with smoking urges

UNIQUE ISSUES FOR PEOPLE WITH MENTAL ILLNESS

• Persistent psychiatric symptoms

• Poor social skill

• Cognitive limitations

•Difficulty forming a therapeutic alliance


• PSYCHIATRIC SYMPTOMS

• Assess psychiatric symptoms each session

• Determine relationship between symptoms and

smoking

• Assess concerns about smoking and their symptoms

• Address symptoms specific coping

• Collaborate with treatment team


•SOCIAL SKILLS

• Drug refusal

• Problem solving

• Reduce anger

• Facilitate conversations

• Asking for social support

• Letting family/friends know they are quitting


•COGNITIVE LIMITATIONS

• Take extra time when warranted

• Use repetition

• Assess understanding of topics

• Enhance self-efficacy

• Cognitive limitations may inflate OR deflate self-

efficacy


•THERAPEUTIC ALLIANCE

• Show empathy- quitting is hard!

• Utilize underlying perspective MI

• Partnership

• Acceptance

• Evocation

• Compassion

• Use Engaging skills of MI

BENEFITS TO QUITTING SMOKING

• You will live longer. People who stop smoking before age 35

avoid 90% of the health risks attributable to tobacco. Even

those who quit later in life can significantly reduce their risk of

dying at a younger age.

• Food will smell and taste better

• Ordinary activities will no longer leave you out of breath

(climbing stairs, light housework)

• You will have more money

• You will have fewer infections including the flu, cold,

pneumonia, and others

• Your skin will have a fresher look and may look younger


• Within 20 minutes

• Blood pressure and pulse goes back to normal

• After 8 hours

• The carbon monoxide level in your blood drops to normal and the oxygen level

increases

• 24 hours after quitting

• Your chance of heart attack decreases

• 2 weeks to 3 months after quitting

• Your circulation improves and your lung function increases up to 30%

• From 1 to 9 months after quitting

• You stop coughing and breathe easier and your overall energy increases. Your cilia

(tiny hair like structures that more mucus out of the lungs) regain normal function in

the lungs, increasing the ability to handle mucus, clean the lungs, and reduce


• 1 year after quitting

• The risk of coronary heart disease is cut in half

• 5 years after quitting

• Your chances of lung cancer death and stroke are cut in half


• The chances of lung cancer are equal to that of a non-smoker. The risk of

cancer of the mouth, throat, esophagus, bladder, kidney, and pancreas

decrease


• The risk of coronary heart disease is the same as a non-smoker

• 1 year after quitting

• The risk of coronary heart disease is cut in half


• Your chances of lung cancer death and stroke are cut in half


• The chances of lung cancer are equal to that of a non-smoker. The risk of

cancer of the mouth, throat, esophagus, bladder, kidney, and pancreas

decrease


• The risk of coronary heart disease is the same as a non-smoker

CONCLUSIONS

• Too few patients receive tobacco dependence

specific treatment; whether that is

pharmacological, psychosocial,

psychotherapeutic, support, or counseling.

•Combinations of medications and therapeutic

treatments will likely be most effective

•Behavioral health professionals have

requisite skills!

RECOMMENDATIONS• Tobacco use disorders should be added to treatment plans and addressed

with appropriate interventions.

• Patients should be properly screened to make sure symptoms being

displayed are not the results of tobacco withdrawal as the symptoms look

similar to other mental health disorders.

• While policy already states smoking on LRC property is against the rules,

all employees should also be unidentifiable as smokers (i.e. smell,

smoking paraphernalia).

• Quit support program for staff

• Education on effects of smoking and possible treatment

• Incentive plan

• Psychiatrists should be educated on the different NRT methods which can

be used for patients diagnosed with a tobacco use disorder so the

TREATING TOBACCO DEPENDENCE IN BEHAVIORAL HEALTH SETTINGS BIBLIOGRAPHY

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Treating Tobacco dependence in mental health settings

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