Tobacco, Mental Illness and Addiction:

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Tobacco, Mental

Illness and Addiction:

A Wake Up Call for Treatment

Professionals

Jill M Williams, MD

Professor Psychiatry Director, Division Addiction Psychiatry Robert Wood Johnson Medical School

Psych Services 2014 Dec 1;65(12):1406-8

Smokers with Behavioral

Health Comorbidity

(Mental Illness and

Addiction) are becoming a

Sizeable Group of Smokers

Left in the US

(2)

US Smoking Prevalence

NCS-R 2001-2003; Diagnoses using CIDI Lawrence et al, BMC Public Health 2009, 9:285

16 million smokers with current

mental illness

~ 1/3 of 51 million smokers in US

23%

None

35% Ever Ill 41% Past Month

Current Smokers by

Mental Illness History

NCS 1992-1993 Lasser et al, 2000

Three Fourths of Smokers have a

Past or Present Problem with

Lasser et al., 2000; Data from National Comorbidity Study

Mental Illness

(3)

Smokers with Behavioral Health

Comorbidity are a Tobacco

Disparity Group

Williams et al., AJPH, 2013

Smoking is the #1 Cause of

Death in People with

Mental Illness or

Addiction

It’s the Smoke that Kills

Cigarette smoke > 7000

compounds

Acetone, Cyanide, Carbon Monoxide, Formaldehyde

>65 Carcinogens

Benzene, Nitrosamines

(4)

Sources of Tobacco Toxins

Thousands; carbon monoxide; formaldehyde; benzene; arsenic, lead; PAH

Nicotine; nitrosamines

More than 600; Ammonia, cellulose acetate; flavors

Recent data from several

states have found that

people with SMI die, on

average, 25 years earlier

than the general

population

National Association of State Mental Health Program Directors Medical Directors Council, July 2006; Miller et al., 2006

http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm

Causes of Death

(8 states: Az, Mo, Ok, RI, Tx, Ut, Vt, Va)

(5)

Reduction in CVD (%) from

Each Risk factor

0 10 20 30 40 50 60 70 10mm SBP/ 5

mm DBP Cholesterol10% walk/ exercise20 min daily Maintain ideal body weight CessationSmoking Hennekens CH. Circulation. 1998;97:1095-1102

50% of deaths in

schizophrenia, depression

and bipolar disorder

attributed to tobacco

Callaghan et al., 2013

Tobacco Causes More Deaths

than any Other Substance

• More alcoholics die from smoking

related diseases than from alcohol

related diseases

• Synergistic effects of alcohol and tobacco ↑ risk of developing pancreatitis and oral cancers • Smoking reduces recovery from cognitive

deficits during alcohol abstinence

Hurt et al, 1996; USDHHS 1982 Durazzo et al, 2007

Smoking Keeps Consumers

from Achieving

Recovery:

Being Financially Stable

Getting Jobs

(6)

Smokers Suffer Financial

Consequences and Lower

Quality of Life

73% 27% Food Shelter Misc. Living Expenses Cigarettes

SteinbergML, et al. Tobacco Control, 2004.

N=68 smokers with schizophrenia on disability income

Persons with

a mental

disorder

or SUD

purchase

& consume

30-44%

of cigarettes

sold in the

US

0 5 10 15 20 25 30 35 40 45 50 Past month MI and SUD (NCS; Lasser 2000)

Nic dep and MI (NESARC;

Grant 2004)

MI estimate no SUD (NSDUH; MMWR 2013)

Stigma: Smoking is a Barrier

to Community Integration

Consumers want Jobs and

Housing

Employers and landlords

highly stigmatize smokers

(7)

Smoke Free Housing

As much as 60% of airflow in multi-unit housing can come from other units

SHS infiltrates through air ducts, cracks, stairwells, hallways, elevators, plumbing, electrical lines SHS is Class 1A carcinogen, in the same class asasbestos

http://www.cdc.gov/healthyhomes/healthy_homes_manual_web.pdf

Tobacco Use May Worsen

Behavioral Health

Outcomes

Cessation Doesn’t Worsen

BH Outcomes

(8)

Improved Mental Health with

Quitting Smoking

• Meta-analysis 26 studies (14 gen pop, 4 psychiatric, 3 physical conditions, 2 psychiatric or physical, 2 pregnant, 1 post-op)

Taylor et al, BMJ, 2014

?? Benefits of Smoking

Cognition

Nicotine/ Nicotinic Receptors  Alzheimer's disease

 Attention deficit disorder

 Autism

 Schizophrenia

Depression

MAO Inhibitor Like Substance

Tobacco

pharmacological

treatment

Not a rationale

for smoking

Suicide and Smoking

• Daily smoking

predicts suicidal

thoughts or attempt (OR 1.82)

– adjusted for prior depression, SUD, prior attempts

• Heavy smoking

Suicide completions

↑Attempts in adolescents (especially girls)

Breslau et al., 2005; Ostacher et al., 2006; Altamura et al., 2006; Iancu et al., 2006; Cho et al., 2007; Oquendo et al., 2007; Riala et al., 2006; Moriya et al., 2006

(9)

Ratio of Suicide Rate: National Average

Grucza et al., NTR, 2014

______ 10 states with weakest TC ________ 10 states with strongest TC

State Excise Tax on Cigarettes State Smoke-Free Air Policies

Covariates included: per capita state mental health agency expenditures, low income, health insurance, rural

An increase of $1 in state excise tax per pack of cigarettes was associated with a 12.4% reduction in risk of suicide.

Smoking cessation in

outpatient SA treatment

• Part of CTN, included methadone sites

• N=225 smokers

SC adjunct or treatment-as-usual (TAU) 9 weeks group counseling plus NP

No negative impact on treatment

No difference in SC vs TAU

on rates of retention in SA tx

abstinence from primary substance

craving for primary substance

.

Reid et al., 2008

Treating Tobacco is not Disruptive

to SUD Treatment

oasas.ny.gov 0 3,500 7,000 10,500 14,000 17,500 21,000 24,500 28,000 31,500 35,000 Au g No v Fe b Ma y Au g No v Fe b Ma y Au g No v # A d m iss ions

No Reduction in Program Admissions

Total For All Major Program Types OASAS NY Tobacco-Free Implementation - July 2008

(10)

Smoking Cessation Treatment Does Not Jeopardize Recovery from other Substances

META ANALYSIS OF 19 RCTs with INDIVIDUALS IN CURRENT ADDICTION TREATMENT or

RECOVERY

• SMOKING CESSATION INTERVENTIONS PROVIDED DURING ADDICTIONS TREATMENT WERE ASSOCIATED WITH A 25% INCREASED LIKELIHOOD OF LONG-TERM ABSTINENCE FROM ALCOHOL AND ILLICIT DRUGS

• SMOKING CESSATION WORKED WELL INITIALLY BUT WAS DIFFICULT TO SUSTAIN IN THE GROUPS • IN THE LATER STUDIES WHICH USED NRT’S, SUCCESS

WAS INCREASED

PROCHASKA ET AL JCCP 2004

Tobacco Use Disorder is a

Behavioral Health

Condition

in the DSM-5

(11)

0 0 100 100 200 200 300 300 400 400 500 500 600 600 700 700 800 800 900 900 1000 1000 1100 1100 0 0 11 22 33 44 5 hr5 hr Time After Amphetamine Time After Amphetamine

% o f B asal R e lease % o f B asal R e lease DA DA DOPAC DOPAC HVA HVA Accumbens

Accumbens AMPHETAMINEAMPHETAMINE

0 0 100 100 200 200 300 300 400 400 0 0 11 22 33 44 5 hr5 hr Time After Cocaine Time After Cocaine

% o f B asal R e le ase % o f B asal R e le ase DADA DOPAC DOPAC HVA HVA Accumbens

Accumbens COCAINECOCAINE

0 0 100 100 150 150 200 200 250 250 0 0 11 22 3 hr3 hr Time After Nicotine Time After Nicotine

% o f B a s a l R e lease % o f B a s a l R e

lease AccumbensAccumbensCaudateCaudate

NICOTINE NICOTINE

Source: Di Chiara and Imperato Source: Di Chiara and Imperato

Nicotine is a Real Drug

Nicotine is a Real Drug

Tobacco Use Disorder

–withdrawal

–tolerance

–desire or efforts to cut down/ control use

–great time spent in obtaining/using

–reduced occupational, recreational activities

–use despite problems

–larger amounts consumed than intended

–Craving; strong urges to use

Most tobacco users are addicted (2 or more

)

DSM-5

Tobacco Withdrawal

4 or more

Depressed mood

Insomnia

Irritability, frustration or anger

Anxiety

Difficulty concentrating

Restlessness

(12)

NRT and Agitation

in Smokers With Schizophrenia

:

• 40 smokers in psych ER

• 21mg patch vs placebo patch

• Usual care for psychosis

• Agitated Behavior was 33% less at 4

hours

and 23% lower at 24 hours for

NRT group

• Better response in lower dependence

• Same magnitude of response as

antipsychotic studies

Allen 2011; Am J Psych

Tobacco Use is Still Part

of Behavioral Health

Culture and We’re not

Doing Enough

(13)

Only 1 in 4 Mental Health Treatment

Facilities Offers Quit Smoking

Services

N-MHSS Report, Nov 2014

Survey of 9048 MH facilities in US (2010)

Less than Half of US Substance

Abuse Facilities Treat this

Substance

National survey of 550 OSAT units (2004–2005) – 88% response rate

41% offer smoking

cessation counseling

or pharmacotherapy

38% offer individual/group counseling 17% provide quit-smoking medication

Friedmann et al., JSAT 2008

41%

Mental health and chemical dependency counselor Joan Ayala. Joan has a dual diagnosis of mental illness and addiction. During her lifelong battle she

has learned coping skills to sustain her and end her

addiction and cope with her mental illness

.

(14)

What to Assess

Severity of Tobacco Use

Disorder

(Level of Dependence)

Motivation to Quit

• Financial Implications • Medical Consequences • Psychiatric Consequences • Other Tobacco Use • Quitting History

Heaviness of Smoking Index

Measure of Dependence

Number of cigarettes per day

(cpd)

AM Time to first cigarette (TTFC

)

≤ 30 minutes = moderate

≤ 5 minutes = severe

Heatherton 1991

Smokers with depression

smoke more cpd and are

more dependent

(15)

80% of Smokers with SMI

report smoking within 30min

of awakening

0 10 20 30 40 50 60 0-5 min 6-30 min 31-60 >60 Williams et al., CMHJ N=100

Smokers in Addiction Treatment are

Moderately to Severely Addicted to

Nicotine

0 5 10 15 20 25 30 35 40 45 50 0-5 min 6-30 min >31 % of sample

N=1882 smokers in NJ addictions treatment, 2001-2002; Williams et al., 2005

Williams NTR 2010

Individuals with schizophrenia highly

addicted

4 minute Nicotine Boost (ng/mL) 25.2 vs. 11.1 ; p<0.01

(16)

48% 41% 55% 43% 40% 22% 24% 24% 28% 20% 0% 20% 40% 60% 80% 100% Methadone Clients Psych. Inpatients Depressed Outpatients General Psych Outpts General Population

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 or addictive disorders are as ready to quit smoking as the general population.

Slide Courtesy J Prochaska; Acton 2001; Prochaska 2004; Prochaska 2006; Nahvi 2006

Patients with SUD Quit

Smoking Successfully

• H/o ETOH Just as likely to

succeed in quitting smoking as

other smokers

• Usual treatments effective

• Smokers learned skills in

recovering from alcohol that

helped them quit smoking

Hughes & Kalman, 2006

Behavioral Health Should Take

a Lead in Tobacco Treatment

• High prevalence of tobacco use/ patient need

• Tobacco Dependence in DSM-V

• Trained in addictions • Tobacco interactions with

psych meds

• Longer and more treatment sessions

• Experts in counseling • Relationship to mental

symptoms and other addictions

Undervalue tobacco use as a problem

• Consumers/ families minimize the health risks of tobacco

• Professionals/ systems have been slow to change in addressing tobacco • Lack the knowledge about

effectiveness of treatment • Lack of advocating for

treatment

Poor reimbursement

(17)

Electronic (Ecig) Components

• Composed of 3 parts:

Cartridges that contains nicotine (flavored)

• Refillable cartridges with different flavors and nicotine • Solution in propylene glycol and glycerin

Heating element to vaporize the nicotine solution

Rechargeable battery

• Microprocessor with a sensor that activates the heating element when the EC is puffed

• LED light

Nicotine intake less than

combustible cigarettes

Farsalinos et al., 2014

E-cigarette

• Made by Big Tobacco

• Safer than cigarette does not mean safe

• Not regulated in sales or advertising

• Not proven effective for cessation

• Risk of re-normalizing smoking behavior

(18)

Past Month Tobacco Use among Youths

Aged 12 to 17: 2002-2013

National Survey on Drug Use and Health

Electronic cigarette

1.5 2.8

4.5

This probably isn't the best way to

quit smoking

(19)

E-joints and e-crackpipes are the

new e-cig

Conclusions

• It’s the smoke that kills

• Numerous consequences from tobacco for

individuals with mental illness and addictions

• Behavioral health professionals MORE

involved in tobacco treatment

• Treat it like a co-occurring disorder

• Program/ Systems changes needed to

support individuals/ treatments

Figure

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References

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