Behavioral Health Data
Tobacco dependence treatment for smokers with mental health and substance abuse disorders is a growing need. Published evidence on best practices to provide cessation services to these populations is growing but limited. The SCLC recognizes there is a need to document current cessation protocols being used to treat these populations and is currently working with its partners to collect such data.
The following offers a collection of presentations, reports and surveys from the field:
PRESENTATIONS
- Tobacco Use in Special Populations: Psychiatric and Substance Use Disorders
- Setting the Stage: Conducting tobacco treatment with clients with substance abuse disorders
REPORTS
Tobacco Cessation in Substance Use Disorder Treatment Facilities: Single State Agency (or SSA) Tobacco Policies - A report by the National Association of State Alcohol and Drug Abuse Directors (NASADAD)
The National Association of State Alcohol and Drug Abuse Directors (NASADAD) Division of Research and Program Applications released a report entitled “Tobacco Cessation in Substance Use Disorder Treatment Facilities: Single State Agency (or SSA) Tobacco Policies.” This report was developed by NASADAD through funding from the Smoking Cessation Leadership Center at the University of California at San Francisco (UCSF). It is available on the NASADAD website at www.nasadad.org. ACCESS THE FULL DOCUMENT HERE.
Report Summary: NASADAD examined State smoking policies within substance use disorder (SUD) treatment facilities, and the challenges faced in implementing policies. The report describes the ways that States have worked with providers to integrate the treatment of tobacco dependence into the context of treating other addictive disorders. The report finds that few State substance abuse agency directors have been given the authority and responsibility to address tobacco cessation among the general populace; instead, this duty resides within agencies with broader mandates.
Over the past fifteen years, a number of State substance abuse agencies have established policies and initiatives to promote smoking cessation within the context of substance use disorder treatment, and others are in the process to develop and implement policies/plans. Most States (as many as 41) do not allow smoking within SUD treatment facilities, and in 12 States, the SSA has formulated a specific policy banning smoking in SUD treatment facilities.
There are also many tobacco cessation resources available to people with SUDs, and to SUD treatment providers. In more than half of the States (26), the State substance abuse agency has administered resources for tobacco cessation including: TA/training/toolkits for providers (26 States); online resources/Quitlines (19 States); and NRTs/counseling (10 States). Though the State substance abuse agency is the lead agency on tobacco cessation in only five States, in many States (at least 42), another agency provides tobacco cessation resources to clients with SUDs and SUD treatment providers.
However, SSAs have limited budgets and competing priorities. Financing has been a major barrier to the integration of smoking cessation services into SUD treatment. There has been very little additional funding available to State substance abuse agencies and SUD treatment providers to offer such services.
Visit http://www.nasadad.org/resource.php?base_id=2093 for access to the full report. For questions or concerns contact Kara Mandell, Research Analyst, at 202-293-0090.
Report Details Tobacco Use Among Missourians with Mental Illness
A report released by the Missouri Foundation for Health (MFH) shows high levels of tobacco use among people receiving mental health services.
MFH funded the study on clients of the Department of Mental Health (DMH) as part of the Department’s effort to address health factors impacting the people it serves.
The overall average rate of tobacco use in Missouri is about 25%, but among consumers of DMH services, the rate is 64%. Serious tobacco-related disorders such as heart and lung disease take on even greater urgency for people grappling with psychological conditions and substance abuse.
Key findings from the study include the following:
- 21% of the DMH consumers surveyed say they typically smoke more than 20 cigarettes per day.
- 56% say they would like to quit using tobacco;
- 66% have made unsuccessful attempts to quit.
- 28% of consumers say their doctors do not regularly remind them to try to quit.
To download a copy of the report, visit www.mffh.org
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SURVEYS
Smoking characteristics of adults with selected lifetime mental illnesses: Results from the 2007 National Health Interview Survey
A new study published in theAmerican Journal of Public Health indicates that the prevalence of smoking is significantly higher among individuals with particular mental illnesses than among the general population and individuals with other mental illnesses. Researchers used data from the 2007 National Health Interview Survey (NHIS) to examine smoking prevalence, frequency, intensity, and cessation attempts among 23,393 adults screened as having serious psychological distress and persons self-reporting bipolar disorder, schizophrenia, attention deficit disorder or hyperactivity, dementia, or phobias or fears. The results showed that the prevalence of current smoking among adults with mental illness ranged from 34.3% (phobias or fears) to 59.1% (schizophrenia), compared with 18.3% of adults without mental illness. The amount of cessation attempts among persons with mental illness was equivalent to attempts among those without mental illnesses or distress, but those with mental illness were less likely to succeed in quitting. Read the abstract of the study here.
American of Pyschiatric Nurses Association- Tobacco Dependence Survey
APNA collected responses from members to develop a set of goals and a tobacco dependence action plan to help mental health nurses reduce/eliminate smoking among patients for whom they provide care. For details on the survey and more information on the Tobacco Task Force visit the APNA task force web page
Los Angeles County, Public Health Department, Mental Health & Substance Use Providers Smoking Cessation Survey: Assessing Knowledge and Attitudes Toward Tobacco Use in Treatment Setting
An online survey was distributed through the Departments of Mental Health Adult Systems of Care and Public Health’s Substance Abuse Prevention and Control. In total, 554 mental health and substance use providers (clinician, physician, RN, LVN/psych tech, recreational/vocational rehab, substance use specialist, or community worker/peer advocate) shared their views regarding their receptivity to smoke-free policies and readiness to integrate smoking cessation interventions into existing services. Findings were presented at the National Conference on Tobacco or Health in Arizona and helped drive the direction of their workplan efforts.
Mental Health America - Readiness of Mental Health America Affiliates to Adopt Tobacco Cessation
Mental Health America conducted quantitative research to assess the readiness of our 300+ affiliates nationwide to adopt tobacco cessation as a priority program area as well as to assess their level of knowledge about the issue and its perceived importance. A summary of the results are as follows:
Knowledge/Awareness: Overall, affiliates underestimate the magnitude of smoking among mental health consumers, specifically:
- The number of mental health consumers who smoke cigarettes. Nearly three-quarters of affiliates believe that half (or fewer than half) of all consumers smoke. However, research suggests that as many as three-quarters of people who have ever had a diagnosed mental health condition are cigarette smokers.
- The number of cigarettes smoked by mental health consumers. When asked to approximate the number of cigarette packs smoked by mental health consumers each year, 95 percent of affiliates selected 500 million or less, as opposed to the real rate of 10 billion.
- The rate of smoking among mental health consumers, as compared with the general population. More than two-thirds of survey respondents believe that people with mental health conditions smoke one-quarter (or fewer) of all cigarettes consumed in the U.S. each year. However, consumers actually account for nearly half of the total U.S. cigarette market.
Attitudes: While affiliates underestimate the magnitude of smoking among mental health consumers, they feel strongly that tobacco cessation among mental health consumers is an important issue, in general, and relevant to recovery.
For instance, nearly all respondents agree that mental health consumers can (98 percent) and want (68 percent) to quit smoking, and that quitting should be a priority for recovery (78 percent).?We need to figure out how to help these vulnerable people deal with their smoking addiction.?
They also feel that more should be done ? in the community, in treatment facilities and among providers ? to help mental health consumers quit smoking. For instance, approximately 80 percent of survey respondents agree that mental health treatment facilities should either become smoke free or at least offer smoking cessation services for consumers. In addition, more than 80 percent of respondents also report that mental healthcare providers can and should help consumers quit. Finally, the majority of respondents (70 percent) feel strongly that their respective organizations should address tobacco use in their constituencies. ?I'm glad to see that this issue is being taken seriously by MHA and it is an issue that needs to be addressed.?
Readiness to Act
However, despite affiliates' overwhelming support for the issue of smoking cessation among consumers, survey respondents are not ready at this time to adopt smoking cessation and prevention as priority programming areas. Nearly 70 percent of affiliates have never addressed tobacco cessation in their programming and, overall, are unsure of how to proceed. Major barriers to adoption include a lack of:
- Knowledge. In addition to underestimating the magnitude of smoking among consumers, the majority of respondents lack knowledge of current statewide activities to address tobacco use in consumers, such as:
- Existing partnerships aimed at reducing the prevalence of smoking among consumers (88 percent);
- Available funding for smoking cessation programs targeting consumers (88 percent); and
- How state Medicaid programs are covering smoking cessation treatments (93 percent).
- Staff Capacity. In addition to a lack of knowledge, respondents are concerned about the potential strain on staff time.
- Resources. Finally, survey respondents are concerned about being able to secure enough funding to launch and sustain effective smoking cessation and prevention programming.
In order to adopt tobacco cessation as a priority program area, affiliates need the following information:
- Data on the prevalence and impact of smoking and smoking cessation among consumers
- Examples of model programs
- A listing of quit hotlines and online resources
Depression and BiPolar Support Alliance: Consumer Survey
Recognizing that smoking cessation can play an important part in health and mental health recovery, the Depression and Bipolar Support Alliance (DBSA), a partner of the National Mental Health Partnership for Wellness and Smoking Cessation, is among the first to reach out to its members to identify consumers 'perspectives on smoking and smoking cessation and to help understand best practices for consumers' quitting plans. Via an online survey, consumers were asked about: 1) smoking habits as they relate to mental health 2) attitudes and beliefs about smoking cessation and 3) experiences with smoking cessation.
Brenda Bergeson, M.D., DBSA director of scientific affairs, reports that of the ~1,000 respondents:
- 74.6% of current smokers expressed a desire to quit smoking
- 64.7% had tried to quit smoking in the last year
- 67% were currently planning to quit smoking
- 74.5% believed that excellent mental health was necessary to successfully quit smoking
- 64.7% of ex-smokers reported that quitting smoking made them feel in control of their lives and improved their mental health.
Data from this project were collected with the intent of developing more effective smoking cessation programs for people living with mental illness.
For more information on DBSA's smoking cessation initiative contact Brenda Bergeson at bbergeson@dbsalliance.org
REPORTS
Tobacco Cessation Leadership Network (TCLN)
- Rates of smoking are 2-4 times higher among people with psychiatric disorders and substance use disorders.
- Nearly 41% of current smokers report having a mental health diagnosis in the last month.
- 60% of current smokers report a past or current history (ever history) of a mental health diagnosis sometime in their lifetime.
- When seeking mental health treatment, heavy smokers report substantially poorer well-being, greater symptom burden, and more functional disability compared to nonsmokers.
- Public mental health clients have a higher relative risk of death than the
general population due, in part, to high rates of tobacco use.
- Among current smokers, the most common ever history of mental health diagnoses are: Alcohol abuse, Major depression, Substance abuse, Anxiety disorders: simple phobias and social phobias.
- Among current smokers, the most common ever history of mental health
diagnoses are:2 Alcohol abuse, Major depression, Substance abuse, Anxiety disorders: simple phobias and social phobias.
- Quit rates among smokers with any current mental health diagnosis are significantly lower than smokers with no history of mental illness.
- Quit rates among smokers with any history of alcohol and substance abuse and social phobias are significantly lower than smokers without this history.
- Quit rates among smokers with a past history of major depression and simple phobias are similar to smokers without this history.
- Multiple explanations have been offered for the high rate of smoking among people with mental illness.
Genetic basis: Shared genetic factors have been identified for nicotine dependence and for depression. Genetic factors likely contribute to the development of schizophrenia and may be contribute to the development of nicotine dependence.
Self-medication: Some researchers speculate that the positive reinforcing effects of tobacco may help manage adverse events due to use of psychotropic medications.
Psychological factors: Smokers with many psychiatric disorders report that smoking reduces their psychiatric symptoms. These smokers are more likely to have higher nicotine dependence levels, have a current history of depression, ADHD, or alcohol dependence.
Trauma: Recent studies have linked a history of grief and PTSD with increased substance use including smoking. In some studies, smokers were found to be more likely to have a history of childhood trauma, which may link to adult depression. Therefore, the initial trauma rather than the later depression could be the risk factor for nicotine dependence.
Social factors: Limited education, poverty, unemployment, peers and the mental health treatment system where tobacco use is generally tolerated and not seen as a health issue may account, in part, for heavier smoking in this population.
Key factors in the treatment of smokers with mental illness.
Under-treatment: Smokers with a mental health disorder are more likely to receive tobacco dependence treatment in a mental health setting and more likely to receive treatment from a primary care provider. All individuals with mental health disorders should be asked if they are smokers and advised to quit. All identified smokers should have smoking cessation integrated into their overall treatment plan.
Timing: There is debate but no clear guidelines about when treatment for nicotine dependence should be introduced during treatment from psychiatric disorders. There is increasing evidence that nicotine dependence treatment does not jeopardize recovery from alcohol and other substances and may improve outcomes.There are emerging recommendations to treat the mental disorder first before attempting to treat nicotine dependence.
Monitoring psychiatric symptoms: There are some reports in the literature indicating that psychiatric symptoms can worsen during the acute stages of withdrawal when individuals are not taking pharmacological treatments for nicotine dependence. There are also reports in the literature indicating that risk for major depression among patients with any history of major depression, increases through the first months following abstinence.
Psychiatric medications: Abstinence from nicotine can increase medication blood levels and risks for medication related adverse events. It is sometimes difficult to distinguish untreated withdrawal symptoms from adverse events from other medications precipitated by a sudden reduction or cessation of nicotine dosing. Therefore, patient monitoring during withdrawal should include consideration of dose adjustments.
Behavioral interventions: There may be a need for more skill development in motivational interviewing and general smoking cessation skills.
Protocols for treatment of smokers with mental illness exist for patients seen in mental health facilities and clinics. These protocols rely on prior knowledge of the smoker’s diagnosis, medication history, and training to monitor symptoms and make medication adjustments.
Protocols for smokers with a history of mental illness who seek tobacco dependence treatment in settings other than mental health facilities and clinics would follow standard tobacco dependence treatment guidelines. Adjustments in these protocols are needed to take into account special risks to achieving abstinence if we are to improve treatment of smokers with a history of mental illness.
Oregon Health & Science University Smoking Cessation Center-TCLN - Bringing Everyone Together Project
A comprehensive model for mental health tobacco recovery in New Jersey
A recent paper inAdministration and Policy in Mental Health outlines a comprehensive model designed to improve access to tobacco cessation treatment for smokers with serious mental illness. The initiatives within the model address the two core goals of the model: to increase demand for cessation treatment, and to help more smokers with mental illness to quit. The model includes the following strategies and initiatives: provide integrated clinical treatment, engage smokers, make changes to the healthcare environment that are conducive to cessation, educate mental health professionals in evidence-based services, provide peer support, raise awareness about the inequities of tobacco use, and increase access to tobacco cessation medications. The initiatives in the model have been tested for feasibility and effectiveness, and the authors hope that this approach will serve as a model for other states. Click here to read the abstract.