TREATING TOBACCO DEPENDENCE in SMOKERS with CO … · Tobacco Documents I am writing to request a donation of cigarettes for long -term psychiatric patients…because of recent changes

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

• 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

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

Trends in cigarette smoking among persons aged 18 or older

0

10

20

30

40

50

60

1955 1959 1963 1967 1971 1975 1979 1983 1987 1991 1995 1999 2003

Year

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

Male

Female

Per

cen

t

22.9%

17.5%

20.9% of adults are current

smokers

SMOKING by DIAGNOSIS

National Comorbidity Survey 1991-1992 Source: Lasser et al., 2000 JAMA

22.5%

34.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

None History

Panic Disorder

PTSD

GAD

Dysthymia

Major Depression

Bipolar Disorder

Nonaffect Psychosis

ASPD

Alcohol Abuse/Dep

Drug abuse/dep

41.0% Overall

Active

SMOKING in CALIFORNIA

15%

28%

45%

CaliforniaAdults

OutpatientPsychiatry

InpatientPsychiatry

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

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

Cigarettes/day

M(SD)

21 (15)

17 (12)

15

TOBACCO KILLS

• 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).

http://images.google.com/imgres?imgurl=http://en.wikipedia.org/upload/9/9d/Cig.packet.750pix.jpg&imgrefurl=http://july.fixedreference.org/en/20040724/wikipedia/Cigarette&h=627&w=750&sz=90&tbnid=ZMj2q5L7dMwJ:&tbnh=117&tbnw=140&start=19&prev=/images%3Fq%3Dcigarettes%26hl%3Den%26lr%3D

TOBACCO & OTHER DRUG USE

• 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)

0

50

100

150

200

250

300

350

400

450

COMPARATIVE CAUSES of ANNUAL DEATHS in the UNITED STATES

Source: CDC

AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced

Individuals with mental illness or substance use

disorders

HEALTH RISKS ASSOCIATED with CHRONIC TOBACCO USE • Cardiovascular disease • 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

COMPOUNDS in TOBACCO SMOKE

– Carbon monoxide – Hydrogen cyanide – Ammonia – Benzene – Formaldehyde

– Nicotine – Nitrosamines – Lead – Cadmium – Polonium-210 – Arsenic

An estimated 4,800 compounds in tobacco smoke

Gases (~500 isolated) Particles (~3,500 isolated)

11 proven human carcinogens

“LIGHT” CIGARETTES

The difference between Marlboro and Marlboro Lights…

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.

• There are no true health benefits to light cigarettes.

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

“NO SAFE” LEVEL of SMOKING

• 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

QUITTING: HEALTH BENEFITS

Lung cilia regain normal function Ability to clear lungs of mucus increases Coughing, fatigue, shortness of breath decrease

Excess risk of CHD decreases to half that of a

continuing smoker Risk of stroke is reduced to that of people who have never smoked

Lung cancer death rate drops to half that of a

continuing smoker Risk of cancer of mouth,

throat, esophagus, bladder, kidney, pancreas

decrease

Risk of CHD is similar to that of people who have never smoked

2 weeks to

3 months 1 to 9

months

1 year

5 years

10 years

after 15 years

Time Since Quit Date Circulation improves,

walking becomes easier Lung function increases

up to 30%

YEARS of SURVIVAL GAINED RELATIVE to CONTINUED SMOKING

10.5

8.5

7.1

2

5.6

3.74.8

7.27.7

8.9

0

2

4

6

8

10

12

NeverSmoked

Quit atage 35

Quit atage 45

Quit atage 55

Quit atage 65

Ad

just

ed G

ain

in Y

ears

of

Su

rviv

al

MenWomen

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

WHY ADDRESS TOBACCO USE in PSYCHIATRIC POPULATIONS?

Prevent Death

Improve Health

Optimize Psychiatric Medication Effects

Reduce Isolation

Patient $ Savings

Tobacco Industry Profits

Interest groups/politicians supported by Tobacco Industry

Tax revenues

SMOKING MENTAL ILLNESS

WHY do INDIVIDUALS with MENTAL ILLNESS SMOKE?

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

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)

FACTORS ASSOCIATED with TOBACCO USE in those with MENTAL ILLNESS

Tobacco Use

Psychological/Behavioral Conditioning effects Coping tool Social interactions Boredom

Biologic & Pharmacologic Genetic predisposition Alleviation of withdrawal Pleasure effects Weight control

Systemic & Treatment Use of cigarettes for reinforcement Tobacco industry marketing efforts

Failure to treat in psychiatry & addiction treatment settings

NEUROCHEMICAL and RELATED EFFECTS of NICOTINE

Dopamine

Norepinephrine

Acetylcholine

Glutamate

β-Endorphin

GABA

Serotonin

N

I

C

O

T

I

N

E

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

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.

Nicotine enters brain

Stimulation of nicotine receptors

Dopamine release

DOPAMINE REWARD PATHWAY Prefrontal

cortex

Nucleus accumbens

Ventral tegmental

area Amygdala

CHRONIC ADMINISTRATION of NICOTINE: EFFECTS on the BRAIN

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

Nonsmoker Smoker

Human smokers have increased nicotine receptors in the prefrontal cortex.

High

Low

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

GENETIC EFFECTS on NICOTINE METABOLISM

Nicotine

~80%

Cotinine

Reprinted with permission, Benowitz et al., 1994.

Norcotinine Cotinine- N-oxide

Cotinine glucuronide

Nicotine glucuronide

Trans-3'- hydroxycotinine

glucuronide

Nicotine Nicotine-1'-

N-oxide Nornicotine

Trans-3'- hydroxycotinine Cotinine Trans-3'-

hydroxycotinine

4.2%

9.8% 4.4%

0.4%

13.0%

12.6%

2.4% 2.0%

7.4%

33.6%

1) CYP2A6 2) Aldehyde oxidase

Source: S.M. Stahl (2000). Essential Psychopharmacology

Source: S.M. Stahl (2000). Essential Psychopharmacology

NICOTINE ADDICTION CYCLE

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

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*

NICOTINE WITHDRAWAL EFFECTS

American Psychiatric Association. (1994). DSM-IV. Hughes et al. (1991). Arch Gen Psychiatry 48:52–59.

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

Most symptoms peak 24–48 hr

after quitting and subside within

2–4 weeks.

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

WHAT is ADDICTION?

“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

SYSTEMIC and TREATMENT FACTORS

PSYCHIATRISTS in PRACTICE (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

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

70%

52%

49%

39%

16%

18%

30%

32%

26%

13%

18%

17%

29%

58%

35%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Arrange follow-up

Assist with quitting

Assess readiness to quit

Advise to quit

Ask about smoking

Never or Rarely Sometimes Often or Always

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

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).

• 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

ATTENTION to TOBACCO USE in ADDICTION TREATMENT

BARRIERS to TREATING TOBACCO

• 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…




Pub. 1951

SMOKING in PSYCHIATRY

Tobacco Documents

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.

Department of Health, Education, and Welfare National Institute of Mental Health

Washington, DC August 4, 1980

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

JCAHO DECISION

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.

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

DSM-IV TOBACCO USE DISORDERS

Nicotine Withdrawal A. Daily use of nicotine B. Abrupt cessation/reduction

followed within 24 hrs by 4+: 1. Depressed mood 2. Insomnia 3. Irritability 4. Anxiety 5. Difficulty concentrating 6. Decreased HR 7. Increased appetite

C. Clinically significant impairment

D. Not due to GMC

Nicotine Dependence Maladaptive pattern of use

with significant impairment manifested by 3+ in 12-months: 1. Tolerance 2. Withdrawal 3. ↑ Use 4. Unsuccessful efforts to stop 5. Time investment 6. Loss of important activities 7. Continued use despite

knowledge of physical or psychological problems

The majority of smokers with mental illness meet criteria for DSM-IV nicotine dependence and

withdrawal (Prochaska et al., 2004; 2006)

http://www.amazon.com/gp/product/images/0890420629/ref=dp_primary-product-display_0/002-4353966-3501601?%5Fencoding=UTF8&n=507846&s=books

TOBACCO IMPACTS TREATMENT

83%

17%22%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Ativan Prescription Placed in Seclusion AMA Discharge*

% o

f Pat

ient

s

NonSmoker (N=129) Smoker, NRT Prescribed (N=59) Smoker, No NRT (N=46)

* 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

PHARMACOKINETIC DRUG INTERACTIONS of SMOKING

• Caffeine • 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

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

Smoking cessation may reverse the effect. (Zevin & Benowitz, 1999)

WHY MENTAL HEALTH and ADDICTION TREATMENT PROVIDERS?

• 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




STUDIES of PSYCHIATRIC PATIENTS’ READINESS to QUIT*

40%

41%

55%

43%

20%

24%

24%

28%

0% 20% 40% 60% 80% 100%

General Population(JO Prochaska et

al., 1999)

Psych. Inpatients(JJ Prochaska et al.,

2006)

Depressed Smokers(JJ Prochaska et al.,

2004)

General Psych Outpt(Acton et al., 2001)

Intend to quit in next 6 mo Intend to quit in next 30 days

* No relationship between psychiatric symptom severity and readiness to quit

Smokers with mental illness are

just as ready to quit smoking as the

general population of smokers.

INTEREST in TREATMENT

• 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)

TIMING of TOBACCO TREATMENT

• 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


• 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 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

STUDY DESIGN

• 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

ABSTINENCE RATES by TREATMENT CONDITION

12%

21%

12%

19%

18%16% 20%

25%

0%

5%

10%

15%

20%

25%

30%

3 6 12 18

Month

7 day

PPA

(%)

InterventionControl

* *

* p<.05 for group comparison

• 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

MENTAL HEALTH OUTCOMES

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

BDI TOTAL SCORE

10

20

Baseline 3 M 6 M 12 M 18 M

Smoking Quit

Minimal

Mild

Moderate

TREATING DEPRESSED SMOKERS

• 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

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

Judith Prochaska, PhD, MPH Kevin Delucchi, PhD & Sharon Hall, PhD University of California, San Francisco Supported by TRDRP #11FT-0013 and NIDA #P50 DA09253 JCCP 2004 Journal of Consulting and Clinical Psychology, 2004

STUDY PURPOSE

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

• 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)

SEARCH RESULTS

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)

DATA EXTRACTION

• 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

DESCRIPTION of STUDIES

• 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)

In Treatment Recovered

Age (yrs) 36 42

Caucasian 60% 94%

Female 32% 54%

CPD 21 31

All comparisons p<.001

INTERVENTIONS

• Psychosocial: – 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

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

http://images.google.com/imgres?imgurl=http://www.isd77.k12.mn.us/CTIC/graphic/Counseling.gif&imgrefurl=http://www.isd77.k12.mn.us/CTIC/&h=163&w=185&sz=3&tbnid=Z0nCSzNhHTsJ:&tbnh=84&tbnw=96&hl=en&start=2&prev=/images%3Fq%3Dcounseling%26svnum%3D10%26hl%3Den%26lr%3D

ANALYSES

• 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).

Post-Treatment Smoking Outcomes EffectName Citation Intervention Control Effect

In Treatment Story 1991 0 / 11 2 / 11 .20In Treatment Burling 1991 0 / 19 0 / 20 1.05In Treatment Campbell 1995 7 / 90 0 / 22 3.79In Treatment Bobo 1995 2 / 30 0 / 60 9.84In Treatment Bobo 1998 7 / 288 5 / 287 1.40In Treatment Cornelieus 1999 1 / 19 0 / 23 3.60In Treatment Kalman 2001 3 / 18 1 / 18 3.00In Treatment Burling 2001 33 / 100 1 / 50 16.50In Treatment Shoptaw 2002 33 / 132 6 / 43 1.79In Treatment Haug 2002 0 / 30 0 / 33 1.10In Treatment Grant 2002 3 / 21 2 / 21 1.50

Random In Treatment (11) 89 / 758 17 / 588 2.03

Recovered Hughes 1993 8 / 14 6 / 24 2.29Recovered Hurt 1995 6 / 13 3 / 18 2.77Recovered Martin 1997 76 / 135 22 / 70 1.79Recovered Patten 1998 9 / 13 5 / 16 2.22Recovered Hayford 2000 15 / 45 4 / 15 1.25Recovered Hughes 2003a 15 / 61 10 / 54 1.33Recovered Hughes 2003b 18 / 111 5 / 49 1.59

Random Recovered (7) 147 / 392 55 / 246 1.77

Random Combined (18) 236 / 1150 72 / 834 1.82

0.01 0.1 1 10 100

Favors Intervention

Figure 1. Post-treatment smoking abstinence rates† for intervention and control conditions and abstinence relative risk estimates

† Number of participants smoking abstinent / total number of participants assigned to the treatment group.Note. 95% Confidence intervals to the right of 1.00 indicates a significant treatment effect

Subgroup Analyses: Post-Treatment Smoking Cessation Effects for In-Treatment Studies

Source No. of studies Summary RR (95% CI)

All studies, participants in current treatment

11 2.03 (1.21 – 3.39)*

Quality score 0 to 2 3 to 5

5 6

1.78 (.77 – 4.11) 2.19 (.85 – 6.86)

Year of publication 1991 – 1999 2000 – 2002

6 4

1.62 (.67 – 3.90) 2.49 (1.12 – 5.53)*

Provision of NRT No Yes

6 5

1.45 (.59 – 3.57) 2.63 (1.21 – 5.70)*

EffectName Citation Intervention Control Effect

In Treatment Story 1991 0 / 11 1 / 11 .33In Treatment Burling 1991 0 / 19 0 / 20 1.05In Treatment Bobo 1995 1 / 30 4 / 60 .50In Treatment Bobo 1998 20 / 288 16 / 287 1.25In Treatment Burling 2001 15 / 100 6 / 50 1.25In Treatment Shoptaw 2002 4 / 132 4 / 43 .33In Treatment Gariti 2002 2 / 34 0 / 30 4.43In Treatment Grant 2003 0 / 21 1 / 21 .33

Random In Treatment (8) 42 / 635 32 / 522 1.00

Recovered Hughes 1993 3 / 14 0 / 24 11.67Recovered Hurt 1995 0 / 13 2 / 18 .27Recovered Martin 1997 38 / 135 15 / 70 1.31Recovered Patten 1998 6 / 13 4 / 16 1.85Recovered Hayford 2000 13 / 45 4 / 15 1.08Recovered Hughes 2003a 4 / 111 3 / 49 .59Recovered Hughes 2003b 13 / 61 8 / 54 1.44

Random Recovered (7) 77 / 392 36 / 246 1.31

Random Combined (15) 119 / 1027 68 / 768 1.18

0.01 0.1 1 10 100

Favors Intervention

Figure 2. Follow-up smoking abstinence rates† for intervention and control conditions and abstinence relative risk estimates

† Number of participants smoking abstinent / total number of participants assigned to the treatment group. Note. 95% Confidence intervals to the right of 1.00 indicate a significant treatment effect

OVERALL SMOKING CESSATION RATES

3%

28%

6%

15%12%

38%

7%

20%

0%

5%

10%

15%

20%

25%

30%

35%

40%

In Treatment In Recovery In Treatment In Recovery

7 da

y PP

A

Comparison Intervention

Post–Treatment Long-term FU 18 studies 15 studies

EffectName Citation Intervention Control Effect

0 Burling 1991 6 / 19 6 / 20 1.050 Bobo 1995 25 / 30 37 / 60 1.350 Bobo 1998 177 / 288 178 / 287 .990 Cornelieus 1999 5 / 19 3 / 23 2.020 Kalman 2001 12 / 18 5 / 18 2.400 Burling 2001 65 / 100 28 / 50 1.160 Shoptaw 2002 27 / 132 9 / 43 .980 Haug 2002 13 / 30 18 / 33 .790 Grant 2003 13 / 21 15 / 21 .87

Random 0 (9) 343 / 657 299 / 555 1.10

1 Burling 1991 6 / 19 5 / 20 1.261 Bobo 1995 24 / 30 34 / 60 1.411 Bobo 1998 93 / 288 65 / 287 1.431 Burling 2001 42 / 100 21 / 50 1.001 Shoptaw 2002 45 / 132 13 / 43 1.131 Gariti 2002 16 / 34 13 / 30 1.091 Grant 2003 6 / 21 9 / 21 .67

Random 1 (7) 232 / 624 160 / 511 1.25

Random Combined (16) 575 / 1281 459 / 1066 1.14

0.1 0.2 0.5 1 2 5 10

Favors Intervention

Figure 3. Substance use abstinence rates† and relative risk estimates for participants in addictions treatment

† Number of participants abstinent / total number of participants assigned to the treatment group.Note. 95% Confidence intervals to the right of 1.00 indicates a significant treatment effect

DRUG & ALCOHOL ABSTINENCE RATES among PARTICIPANTS IN TREATMENT

54%

31%

52%

37%

0%

10%

20%

30%

40%

50%

60%

Post-Treatment Long-Term FU

% a

bstin

ent

Comparison Intervention

9 studies 7 studies

CONCLUSIONS

• 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 improved sobriety among intervention participants – 25% greater odds of being sober if exposed to

the tobacco cessation intervention

CONCLUSIONS

• 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




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

5

9

3

21

26

0% 20% 40% 60% 80% 100%

Other

On the job

CME

Psych Residency

Med School

None Inadequate Adequate

Prochaska et al., 2005 Acad Psychiatry

INTEREST in FURTHER TRAINING

Moderately Interested,

37%

Very Interested,

39%

Not at all, 1%

Not very, 5%

Extremely Interested,

18%

94%


NATIONAL SURVEY of PSYCHIATRY RESIDENCY TRAINING DIRECTORS

• 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


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)

RESULTS: Knowledge

• Gains in knowledge scores significant from pre- to post-training, averaging +17 percentage points, – t51= 7.32, p<.001

• Significantly associated with attendance

0

5

10

15

20

25

1 to 2 hrs 2.5 to 3.5 hrs all 4 hrs

Attendance at Training

% C

han

ge

in k

no

wle

dg

e sc

ore

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

RESULTS: Attitudes

1

2

3

4

5

Pre-training Post-training 3-month

scale score

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

* **

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

High

Low

RESULTS: Attitudes

Barrier Attitudes Pre Post 3 mo FU Comparisons*

A focus on smoking cessation would detract from management of patients' psychiatric symptoms. 2.45 2.00 1.85 T1 > T2, T3

Asking my patients about their smoking may make them angry or defensive. 2.73 2.44 2.20 T1 > T2, T3

I don't want to take away an enjoyable and rewarding activity from my patients. 2.20 1.92 1.78 T1 > T2, T3

I don't ask about my patients’ smoking because I don't think they'd be able to quit. 2.51 1.71 1.74 T1 > T2, T3

If my patients want help with quitting smoking, they will ask for it. 2.33 1.77 1.69 T1 > T2, T3

My patients should wait until their psychiatric issues are resolved before trying to quit smoking. 2.11 1.63 1.48 T1 > T2, T3

Attempts to quit smoking are likely to make my patients' current drug or alcohol use worse or make them relapse.

2.31 1.87 1.57 T1 > T2 > T3

My patients need to smoke to manage their symptoms (e.g., anxiety, depression). 2.29 1.54 1.76 T1 > T2, T3

Smoking cessation should preferably be handled by nonpsychiatric providers. 2.07 1.67 1.83 T1 > T2

Smoking cessation is not a priority for psychiatry. 2.07 1.71 1.81 T1 > T2

Mean total score 2.32 1.83 1.77 T1 > T2, T3

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

RESULTS: Confidence

1

2

3

4

5

Pre-training Post-training 3-month

scale score

Extremely confident

Not at all confident

* **

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

RESULTS: Confidence

All pre-post comparisons significant at p<.05

1 2 3 4 5

Refer for tob tx

Relapse prevention

Assist given limited time

Assist pt with quitting

Knowledge of meds

Motivate pt to quit

Advise pt to quit

Pre-training Post-training

RESULTS: Self-reported Behaviors

16%

+20%

+24%+29%

+27%+2%

0%

10%

20%

30%

40%

50%

60%

Asked abouttobacco use

Advised*patient to quit

Assessed*readiness to

quit

Assisted* withquitting

Arranged*follow up

Refer*

% o

f pat

ient

s

Pre-training 3-month follow-up

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

RESULTS: Charted Behaviors Baseline to 3 month follow-up (N=1204 medical records)

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

0%

5%

10%

15%

20%

25%

30%

35%

40%

Asked Advised Assessed Assisted Arranged

Trained: pre-test Trained: 3 mo FU Untrained: pre-test Untrained: 3 mo FU

+12%

+22%

+32%

+16%+19%

+1%

+1%+3% +3% +3%




MEDICARE / MEDI-CAL

• 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)

COMPARATIVE DAILY COSTS of PHARMACOTHERAPY

Cost per day, in U.S. dollars

0 1 2 3 4 5 6 7

Clonidine

Nortriptyline

Patch

Bupropion SR

Gum

Nasal spray

Chantix

Cigarettes (1 PPD)

Lozenge

Inhaler

$3.75 generic $5.00 in CA $5.88

$3.67 $4.00

$3.48 (generic) $2.84 (generic)

$6.07

$1.13 (generic) .91¢ (generic)

$2.62 (generic)

FINANCIAL IMPACT of SMOKING

0 250 500 750 1000Hundreds of thousands of dollars lost

$1,004,196

$753,147

$502,098

Packs per day

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

1

1.5

2

ANNUAL SMOKING-ATTRIBUTABLE ECONOMIC COSTS—U.S., 1995–2001

0 10 20 30 40 50 60 70 80 90

Annual lost productivity

costs (1997–2001)

Medical expenditures

(1998)

Billions of dollars

Men, $61.9 billion

Ambulatory care, $27.2 billion

Prescription drugs,

$6.4 billion

Women, $30.5 billion

Nursing home, $19.4 billion

Other care, $5.4 billion

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

Hospital care, $17.1 billion

Societal costs: $7.65 per pack


• 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

• “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

ACKNOWLEDGEMENTS

• 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)