DATA

Tobacco dependence treatment for smokers with mental health and/or 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 two presentations offer population data.

• Tobacco Use in Special Populations: Psychiatric and Substance Use Disorders
• Setting the Stage: Conducting tobacco treatment with clients with substance abuse disorders

Readiness of Mental Health America Affiliates to Adopt Tobacco Cessation Final Report to the Smoking Cessation Leadership Center

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

Tobacco Cessation Leadership Network (TCLN) fact sheet

Download the full Tobacco Cessation Leadership Network (TCLN) fact sheet for a list of references.

• 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