Smoking and Persons with Serious Mental Illness

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Slide 1 : Smoking and Persons with Serious Mental Illness Pat Penn, PhD & Sandra Gallagher, PhD La Frontera Center, Inc. Tucson, Arizona ppenn@lafrontera.org sgallagher@lafrontera.org Presented at the Behavioral Oncology Seminar Series, Tucson, AZ, October 2, 2007
Slide 2 : Educational Objectives Provide facts about nicotine addiction and its impact, especially as it relates to persons with serious mental illness (SMI) Introduction to interventions Results from our treatment study
Slide 3 : Cigarette Smoking in the U.S. 22% of U.S. Population (2005) 20.8% of Arizonans (2005) But…
Slide 4 : NEARLY EVERY OTHER CIGARETTE SMOKED IN THE U.S. IS SMOKED BY SOMEONE WITH A PSYCHIATRIC DIAGNOSIS!! Lasser, 2000
Slide 5 : Psychiatric Conditionsand Tobacco Use Other Chemical Dependency 90% Psychotic Disorders 85% Posttraumatic Stress Disorder 85% Affective Disorders Bipolar Affective Disorder 70% Major Depressive Disorder 40% Anxiety Disorder 35% Addictive Behavior 1998
Slide 6 : Schizophrenia and Tobacco Use Cigarette smoking is 3 times higher than in the general population. Persons with schizophrenia: Are more highly addicted, Have poor health care, more at risk of chronic health effects, and Cigarette smoking may relieve some symptoms and decreases neuroleptic-induced parkinsonism. American Journal of Psychiatry 1998
Slide 7 : Depression and Tobacco Use Individuals with a history of depression are 1.6 times more likely to be smokers. Nicotine withdrawal symptoms can include depressive symptoms. Persons with histories of major depression or anxiety disorders report more severe withdrawal symptoms.
Slide 8 : Cost of Tobacco A two pack-a-day smoker can spend more than $2000-3000 per year on cigarettes. Many of our clients on SSI/SSDI receive about $9000 per year.
Slide 9 : Most Tobacco UsersWANT to Quit 70%+ of smokers say they want to quit Includes psychiatric populations too: our survey = 58% of persons with SMI 50%+ have made at least one serious attempt to quit. There are a variety of treatments with documented success
Slide 10 :
Slide 11 : Cost-Effectiveness of Smoking Cessation Interventions Tobacco cessation treatments shown to be effective in the PHS Guideline are highly cost-effective relative to other reimbursed treatments. (e.g., hypertension, hyperlipidemia, mammography, Papanicolau smears) PHS 2000
Slide 12 : But…
Slide 13 : The Emperor’s New Cigarette Persons with mental illness have been largely excluded from cessation research Are often overlooked by traditional cessation providers Cigarettes kill more people every year than alcohol, drugs, accidents and suicide combined Average age of death for persons with SMI at La Frontera = 50
Slide 14 : We can’t continue to ignore nicotine addiction’s high costs in this vulnerable population!
Slide 15 :
Slide 16 : How Addictive is Nicotine?Addiction Criteria: 1. Taking the drug more often or in larger amounts than intended 2. Unsuccessful attempts to quit; persistent desire, craving 3. Excessive time spent in drug seeking 4. Feeling intoxicated at inappropriate times, or feeling withdrawal symptoms from a drug at such times 5. Giving up other things for the drug
Slide 17 : Addiction Criteria (cont.) 6. Continued use, despite knowledge of harm to oneself and others 7. Marked tolerance in which the amount needed to satisfy increases at first before leveling off 8. Characteristic withdrawal symptoms for particular drugs 9. Taking the drug to relieve or avoid withdrawal
Slide 18 : Henningfield Ratings
Slide 19 : How Addictive is Nicotine? The urges produced by nicotine are very similar to those from heroin. Drugs rank differently on the scale of how difficult they are to quit as well, with nicotine rated by most experts as the most difficult to quit. If the question is, “How hard is it to stop?” then nicotine is a very impressive drug.
Slide 20 :
Slide 21 : Psychiatric Diagnoses and Cessation Nicotine withdrawal may exacerbate psychiatric conditions, although most evidence suggests that abstinence entails little adverse impact. Discontinuing tobacco use may result in the need for lower doses of medications.
Slide 22 : Abstinence Increases Some Medication Blood Levels Tobacco affects liver enzymes Antidepressants Antipsychotics Antianxiety medications Other substances: caffeine, acetaminophen
Slide 23 : Psychiatric Diagnoses and Cessation However for some populations…. Smokers with a history of major depression who quit were at higher risk of a new major depressive episode than persons with a similar history who continued to smoke (Glassman, 2001) History of depression, not necessarily history of addiction, predicts cessation failure A small proportion of patients may be at risk for psychiatric/drug relapse when quitting -- had emergent symptoms in prior quit attempts (Hughes, 2005) Need to screen for depression, monitor these clients more carefully, proactively treat
Slide 24 : Efficacy of Healthcare Professional Interventions Interventions by nurses, physicians, counselors, psychologists, pharmacists, and health educators… Increased quit rates 70 - 120% PHS 2000
Slide 25 : Intensity of Treatment by Healthcare Professionals Compared to no contact: Minimal contact (< 3 minutes) increased quit rates 30%. Low Intensity counseling (3-10 minutes) increased quit rates 60%. Counseling (> 10 minutes) increased quit rates 130%. PHS 2000
Slide 26 :
Slide 27 : Pharmacotherapy for Treating Tobacco Dependence By using the pharmacotherapies found to be effective, clinicians can double or triple their consumers’ chances of abstinence. Pharmacotherapies are effective for a broad range of smokers, not just “hardcore” smokers. PHS 2000 ES
Slide 28 : Efficacy of Medical Interventions Nicotine gum 15% Nicotine patch 20–25% Nasal spray 20-25% Inhaler 25-30% Wellbutrin/Zyban® 25-30% Wellbutrin/Zyban® & patch 30-35% 50% increase in successful outcome with the addition of behavior therapy ES
Slide 29 : Nicotine Patch Dosage and Duration: 21mg/24hr (4 weeks), then 14mg/24hr (2 weeks), then 7mg/24hr (2 weeks) 15mg/16hr, 10mg/16hr, 5mg/16hr (8 weeks) Cost/day: $4.00-$4.50 (generic patches may be less) Efficacy: Odds ratio 1.9 (n=27 studies) Abstinence rate 17.7% ES
Slide 30 : Contingent Reinforcement Based on behavioral principles Alters salience of a target behavior and the reinforcements around that behavior Used for different types of drug cessation Pilot studies with smokers with schizophrenia
Slide 31 : Our Study: Smoking Cessation in Persons with Serious Mental Illness Funded by ABRC (was ADCRC) Recruited clients with diagnoses of schizophrenia or other serious mental illness. Randomly assigned 180; intervened with 120 Compared: contingent reinforcement, contingent reinforcement + NRT (patch), and “self-quit” or minimal intervention.
Slide 32 : Intervention Two active intervention groups met individually with staff 12 times over 36 weeks. 21 mg patches were distributed for 16 weeks Sessions included recording weight, BP, pulse, expired CO, self-reported withdrawal symptoms and NRT status (if relevant), as well as other self-report measures
Slide 33 : Intervention, cont. Participants received CR for expired CO below 10 ppm Staff took a client-centered approach and frequently discussed life stressors and strategies related to supporting cessation
Slide 34 : CR Schedule(Expired CO <= 10 ppm) Weeks 1 – 4 = $20.00 Weeks 6, 8, 10 & 12 = $40.00 Weeks 16, 20 & 24 = $60.00 Week 36 = $80.00 Baseline & Follow-up data collections = $25.00 All other data collection visits = $5.00 Total if attend all visits and achieve CO goal = $580.00
Slide 35 : Measures Smoking history Health history Substance abuse screen Fagerström Tolerance BSI Smoking Cessation Quality of Life Salivary Cotinine Weight, BP, pulse Expired CO NRT status Withdrawal symptoms Relief of craving Smoking-related symptoms Self-reported smoking
Slide 36 : Recruitment Recruited 231, enrolled 181(78.4%) Those enrolled did not differ in age, gender, or income from those not enrolled The groups significantly differed at baseline, on ethnicity and whether they were diagnosed with a psychotic-spectrum disorder but these had no effect on outcomes.
Slide 37 : Demographics
Slide 38 : Outcomes – Quit Rates
Slide 39 : Psychiatric Exacerbation An analysis of the Brief Symptom Inventory (BSI) total scores at baseline, end of active intervention (week 16/20), and follow-up (week 36), indicated that there was NO significant change in self-reported psychiatric symptoms for any of the groups over time.
Slide 40 :
Slide 41 :
Slide 42 : Harm Reduction Although quit rates were low, our participants reported significant reduction in the number of cigarettes smoked over time in the two intervention groups. These participants cut down to about one third the number of cigarettes they had been smoking at baseline. The control group cut down very little if at all.
Slide 43 :
Slide 44 : Qualitative Results Allowing participants to commit to harm reduction (i.e., cutting down v. total abstinence) was crucial for engagement and retention Relationship with clinical research staff was vital Mentioned factors that helped/hindered and benefits of quitting Stressors implicated in relapse
Slide 45 : Results Summary Contrary to previous findings, NRT did not improve quit rates for this group NRT adherence was very low, which lead to very low power to detect a difference CO group appears to have learned to cut down temporarily in order to receive reinforcement; this was reframed as successful demonstration of their ability to control their smoking Importantly, there was no evidence of psychiatric exacerbation during quit attempt
Slide 46 : Suggestions for Future Work More frequent CO monitoring & reinforcement Need to include measures of life stress Include interventions for relapse prevention and stress management - a best practice for other co-occurring disorders Follow-up those who significantly cut down to determine the course of smoking Conduct focus groups to elicit cessation strategies & barriers unique to this population
Slide 47 : Implications Nicotine addiction is a co-occurring disorder Harm reduction is best practice in other co-occurring disorders treatment but controversial in smoking cessation because some say there is no such thing as a “safe” number of cigarettes. Harm reduction may be an appropriate initial outcome with abstinence as a more long-term goal because this supports engagement and self-efficacy
Slide 48 : Implications, cont. While there is no “safe cigarette”, if a person with a serious mental illness reduces from 30+ cigarettes/day to 5-10 cigarettes/day, could this be considered a positive treatment outcome? Perceived improved physical well-being Health benefits are dose-related Significant cost savings
Slide 49 : Conclusion:Give the Emperor some clothes! The majority of persons with serious mental illness want to quit or significantly reduce smoking – and they can - but… More research with this population is needed and Is feasible This vulnerable population deserves our continued interest and increased treatment efforts
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