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Tupeka Kore Aotearoa 2020 Tobacco Free New Zealand 2020 Implications for smoking cessation practice Mark Wallace-Bell PhD RN National Heart Foundation Canterbury University Health Sciences Behaviour Change Consultancy Ltd Big Tobacco, Big Lies Smoking is an informed choice Smoking helps cope with – stress – depression – anxiety smoking is not promoted to children and vulnerable groups YEH RIGHT! % Adult smoking by ethnic group 45 40 35 30 25 20 15 10 5 0 Asian European Census 2006 Pacific NZHS 2006/07 Maori Health inequalities in NZ 85 Life expectancy in years 80 75 70 65 60 55 50 1950 1960 1970 Non-Mori (SNZ) Male Mori (SNZ) Male Mori (NZCMS ) Male M_ori (MoH latest ) Male 1980 1990 2000 Non-Mori (SNZ) Female Mori (SNZ) Female Mori (NZCMS ) Female M_ori (MoH latest ) Female Source: Blakely T, et al. Soc Sci Med 2005:2233-2251. N Z Med J 2008;121:7-11. 2010 How tobacco is framed dictates how it is treated Could be framed as a poison; a drug; a tax source A medicine (nicotine); a commodity/legal product for commercial trade; a private behaviour; (an illegal substance) Current framing mainly as a (risky) commodity and a tax source, and governments reluctant to intervene in a commercial transaction Needs to be framed as a poison by society and government, and as an issue about general societal well-being, not just a health sector issue It is proposed that the tupeka kore / tobacco free Aotearoa / New Zealand vision is achieved through 3 key goals that will be met by 2020. These are: Tobacco products will not be available as consumer products in Aotearoa/New Zealand Children will be protected from exposure to tobacco and the marketing and promotion of tobacco products All smokers will be empowered to quit and will be supported by effective quit smoking support services and products. In order to achieve these goals it will be vital to engage the widespread support and empowerment of health professionals, communities, iwi/hapū, businesses and local and national policy makers . All smokers will have full access to state of the art quit-smoking support services and products through the following policies: A full range of effective quit smoking options will be available to all smokers at minimal costs All health care professionals will understand and implement quit- smoking interventions and referrals Nicotine Replacement Therapy will be widely accessible through retail outlets including dairies, supermarkets, coffee shops, cinemas, sports grounds and any place where smokers are likely to be customers Education will change misconceptions about nicotine that currently act as a barrier to the use of quit smoking products Product innovation of effective and safe ways to manage nicotine addiction will be encouraged Cigarettes will be phased out as a consumer product Sinking Lid Approach Massive ↑ Cessation, mass media; 90% pack warnings Tobacco Imports Display free stores; Plain packaging; no duty free Licensing retailers; reducing license numbers Alternative nicotine delivery systems Altering tobacco (e.g. zero nicotine cig.) 2010 2012 2014 2016 2018 2020 We have made a start But..the current situation is unacceptable We need to change the script – Tobacco is a poison – Tobacco resistance not control – Tobacco as a social justice and development issue – Nicotine addiction treatments given priority – Challenge addiction and MH sector to show leadership – Change the ‘self-medication’ culture We need to raise our game and our ambitions 11 Smoking in Nurses Smoking and MH/AOD disorder in NZ 80 70 60 50 Non_Maori Maori 40 30 20 10 0 Male Female Any Anxiety Disorder Any Mood Disorder Any Substance Disorder Any Disorder No disorder Selected data from Te Rau Hinengaro: The New Zealand Mental Health Survey (Ministry of Health, 2006). Prevalence of Smoking in the Psychiatric Population P<.001 P<.001 Lifetime Smoking Rates (%) 70 60 55.3 59.0% 50 40 39.1 30 20 10 0 No Psychiatric Disorder Lasser et al. JAMA. 2000;284(20):2606-2610. Lifetime Psychiatric Disorder Past-Month Psychiatric Disorder Increased Cigarette Consumption in Smokers With Psychiatric Disorders 27 26.2 Cigarettes/Day 26 25 24 23 22.6 22 21 20 Current Smokers Without Psychiatric Disorders in the Past Month (n=746) Lasser et al. JAMA. 2000;284(20):2606-2610. Current Smokers With Psychiatric Disorders in the Past Month (n=511) Underdiagnosis of “Nicotine Dependence” in the Psychiatric Setting Mental Health Records Documented (%) 100 88 80 60 40 20 2 0 Tobacco Use Peterson et al. Am J Addict. 2003;12:192-197. Diagnosed Nicotine Dependence Smoking: Risk Factor for Psychiatric Disorders Odds Ratio (95% CI)a,b,c Estimated effects of preexisting daily smoking varies across disorders 9.0 6.0 4.4 3.2 3.6 2.6 3.0 0.0 Major Depression Dysthymia Panic Disorder Agoraphobia GAD=generalized anxiety disorder. These models predict the subsequent onset of specific disorders in all daily smokers, without controlling for other psychiatric disorders that preceded the onset of daily smoking and without taking into account the proximity and intensity of smoking. aThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons. bFrom a series of 10 survival models for first onset of specific disorders associated with prior daily smoking as time dependent, adjusted for race, sex, age, education, and same-year onset. cP.05. Breslau et al. Psychol Med. 2004;34:323-333. Psychiatry and Smoking Psychiatric patients who smoke have 30 % Illicit Drug Use – Higher incidence of illicit drug use 22.3 20 P=.0000 10 2.9 0 Nonsmokers Current Smokers Noncompliant With Treatment – Poorer treatment compliance % 60 40 20 39.0 P=.0000 16.3 0 – Lower Global Assessment Functioning (GAF) score Montoya et al. Am J Addict. 2005;14(5):441-454. GAF Score 50 Nonsmokers 60 40 Current Smokers P=.000 52.3 30.9 20 0 Nonsmokers Current Smokers Nicotine Addiction: Social and Psychological Factors Smoking – Accepted part of the culture in many psychiatric treatment facilities – Shared social activity – Barrier to achieving relationships, employment, and housing for psychiatric patients Williams et al. Addict Behav. 2004;29:1067-1083; Reuters UK. http://uk.reuters.com/article/personalFinanceNews/idUKNOA82640920070629. Accessed September 25, 2007. Severity of Withdrawal and Psychiatric Disorders Smokers with a history of psychiatric disorders have a higher likelihood of experiencing severe withdrawal Odds Ratio (95% CI)a 70 60 50 40 30 16.29 20 10 0 aThe 21.81 6.28 3.91 Major Alcohol Depression Dependence Conduct Disorder Agoraphobia 6.42 Social Phobia ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons. Madden. Addiction. 1997;92(7): 889-902. Summary: Smoking and Psychiatric Disorders Smoking is highly prevalent in the psychiatric population Nicotine-dependent smokers in the mental health population – Smoke greater quantities – Frequently are underdiagnosed – Have a higher incidence of illicit drug use, poorer treatment compliance, and lower GAF scores – May derive symptomatic relief from their psychiatric disorders as a result of smoking Estimated effects of preexisting daily smoking varies across disorders Active psychiatric disorders may predict an increased risk of smokers’ progression to nicotine dependence Numerous social and psychological factors play a role in the perpetuation of nicotine dependence in the mentally ill Increased Rate of Suicide in Smokers Annual Suicide Rate per 100,000 by Cigarettes Smoked/Day There is a strong association between heavy smoking and high suicide rate 60 57 40 29 23 33 26 20 0 Never Smokers Ex-smokers 1-14 15-24 Cigarettes/Day Current Smokers Men Doll et al. BMJ. 1994;309:901-911. 25 Increased Risk of Suicidal Behavior Tobacco use is associated with an increased risk in suicidal behavior among adolescents and adults, independent of other substance use, depressive symptoms, and prior suicidal ideation P<.05 Odds Ratio (95% CI)a 3.0 1.82 2.0 1.00 1.09 1.0 0.0 Never Smokers aThe Ex-smokers Current Smokers ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed person. Adjusted for history of major depression, alcohol, and drug use disorders. Breslau et al. Arch Gen Psychiatry. 2005;62:328-334. Suicidal Behavior and Serotonin 120 the quantity of cigarettes smoked and CSF 5-HIAA (index of serotonin function) (P.003) Reduced CSF 5-HIAA concentration is independently associated with – History of a higher lethality in suicide attempts – Severity of lifetime aggression CSF 5-HIAA (pmol/mL) Inverse relationship between 100 80 60 40 20 0 0 1-20 21-39 40 Cigarettes/Day Current Smokers CSF 5-HIAA=cerebrospinal fluid 5-hydroxyindoleacetic acid. Malone et al. Am J Psychiatry. 2003;160:773-779; Placidi et al. Biol Psychiatry. 2001;50:783-791. Smoking–Suicide Connection: Possible Explanations Smoking – Is a form of self-medication for depression, a common antecedent of suicide – Alters brain chemistry, leading to depression, which increases the risk of suicide – Is associated with an increased risk of cancer, which increases the risk of suicide – Is associated with other characteristics that predispose individuals to suicide (eg, low self-esteem) Miller et al. Am J Public Health. 2000;90:768-773. Smoking and Schizophrenia Among the mentally ill, smoking prevalence is highest in patients with schizophrenia (~70%-90%) Schizophrenic patients smoke at nearly 3 times the rate of the general population Smokers with schizophrenia experience increased – Psychiatric symptoms – Number of hospitalizations – Medication doses Williams et al. Addict Behav. 2004;29:1067-1083; Dalack et al. Am J Psychiatry. 1998;155:1490-1501; http://www.istockphoto.com/file_closeup/who/character_traits/weakness/2700932_temporary_solution.php?id=2 700932. Accessed October 11, 2007. Financial Implications of Smoking Among Schizophrenic Patients Smoking imposes a significant financial burden on patients with schizophrenia Monthly Budget 27.4% Cigarettes Food, Shelter, Other 72.6% Steinberg et al. Tob Control. 2004;13:206-208. Schizophrenia: Coronary Heart Disease (CHD)-Related Morbidity Compared with the general population, patients with schizophrenia – – – – Have a 20% shorter life expectancy 2-fold higher risk of CHD Twice as likely to die of CHD Major risk factors for CHD are more common—smoking, hypercholesterolemia, hypertension, obesity, and diabetes 50% to 75% of patients with schizophrenia have CHD CHD=coronary heart disease. Hennekens et al. Am Heart J. 2005;150:1115-1121; Reader’s Digest Canada. http://www.readersdigest.ca/mag/2002/12/heart_attack.html. Accessed September 25, 2007. Schizophrenia: Increased SmokingRelated Mortality Standardized Mortality Ratio (SMR)a 500 P=.05 360 400 300 200 178 100 0 Nonsmokers aStandardized Current Smokers mortality ratio is the number of deaths observed divided by the number of deaths expected and multiplied by 100. An increased SMR is statistically significant when the lower confidence interval (95% CI) is 100 or more. Brown et al. Br J Psychiartry. 2000;177:212-217. Nicotine Dependence and Anxiety Young adults with nicotine dependence have greater odds of developing anxiety disorder Odds Ratio (95% CI)a 4 3 2.4 2 1 1.4 1.0 0 Nonsmokers aThe Dependent Smokers Nondependent Smokers ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons. Adjusted for sex and other substance dependencies. Breslau et al. Behav Genet. 1995;25(2):95-101. Conclusions Smoking is highly prevalent in the psychiatric population Compared with the general population, schizophrenic and depressed smokers are less likely to successfully quit smoking, although smokers with panic disorder have higher cessation rates Smokers with psychiatric disorders may smoke to ameliorate their pathologic symptomatology There appears to be a distinct association between smoking and suicide Environmental/social stimuli associated with smoking play a role in reinforcing nicotine dependence Implications for treatment There is little need for concern that smoking cessation will provoke relapse in patients with history of psychiatric disorder There is no good evidence that stopping smoking worsens psychotic symptoms in the long term; other symptoms may be improved 32 Implications for treatment Smoking cessation may be a useful intervention to improve minor psychiatric symptoms Treating untreated minor psychiatric symptoms may improve smoking cessation outcomes Smoking cessation treatment in psychiatric patients will need to be more intensive and prolonged and in some cases need to address other needs 33 Higher Dose NRT Products Are Better For More Dependent Smokers Nicotine gum: 4mg vs. 2mg – 4mg much more likely to be effective for highly dependent smokers Nicotine lozenge: 4mg vs. 2mg – 18% quit vs. 10% in 2mg group – 15% quit vs. 6% in 4mg group Nasal spray much better than placebo for highly dependent smokers Silagy, C., et al., Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev, 2004(3) “Cut Down To Quit” Using NRT to help reduce consumption for 6-8 weeks prior to quitting might increase quit rates It may be helpful for smokers who have tried many times before? Shiffman, S., Ferguson, S. G. & Strahs, K. R. (2009) Quitting by gradual smoking reduction using nicotine gum: a randomized controlled trial, Am J Prev Med, 36, 96-104 Latest news and views Traditional programmes for smoking cessation may not always be suitable for psychiatric patients due to their neuropsychological profile. The evidence suggests that more flexible, open-ended, combination approaches of pharmacotherapy and counselling may be more successful. Fagerstrom & Aubin Curr Med Res Opin. 2009 Feb;25(2):511-8 36 Latest news and views Solty et al Can J Psychiatry. 2009 Jan;54(1):36-45 – Self-reported motivation to quit is high in psychiatric inpatients Hettema et al Jnl Consult Clinical Psy, 2010:78(6):868-884 – Motivational Interviewing for smoking cessation is effective Kinnunen Int J Psychiatry Med. 2008;38(3):373-89 – NRT works in depressed and non-depressed smokers Covey et al Nicotine Tob Res. 2008 Dec;10(12):1717-25 – Combined bupropion and nicotine patch treatment appears to be helpful Some emerging evidence that champix may be effective 37 Latest new and views Zadonis et al Nicotine Tob Res. 2008 Dec;10(12):1691-715 NIMH report. Historically, "self-medication" and "individual rights" have been concerns used to rationalize allowing ongoing tobacco use and limited smoking cessation efforts in many mental health treatment settings. Although research has shown that tobacco use can reduce or ameliorate certain psychiatric symptoms, overreliance on the self-medication hypothesis to explain the high rates of tobacco use in psychiatric populations may result in inadequate attention to other potential explanations for this addictive behavior among those with mental disorders. 38 Hei Aha Te Kai Paipa, Me Waiho Smoke-free Strategy for Mental Health Nurses 2010-2013 Tobacco cessation for people with mental illness or addictions should be integrated into existing mental health and addictions services. Service providers including health professionals need sufficient support and training to incorporate tobaccorelated interventions into their practices. Education includes information that dispels myths about mental health and nicotine dependence and supports best practice evidence. Hei Aha Te Kai Paipa, Me Waiho Smoke-free Strategy for Mental Health Nurses 2010-2013 Nicotine replacement therapy should be provided to all individuals with mental illness or addictions who want to quit or reduce their smoking. Individuals who are taking antipsychotic medications and quit smoking should have their medication dosages monitored in the first months following cessation. Multi-session intensive support, medication and followup for all hospitalised patients who smoke. Consistent approach to smoking cessation across hospital inpatient and community based services ensures service users receive care consistent with the care plan.