Transcript Smoking - National Treatment Agency for Substance Misuse

Smoking and
Substance Misuse
Slides by Ann McNeill, Luke
Mitcheson and Gay Sutherland
Institute of Psychiatry, KCL
Summary


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Relationship between smoking and
substance misuse and treatment
Local audits
NICE guidance
Next steps?
n 3 million smokers in UK
with a mental health
disorder
n No change in
prevalence in last 20-30
yrs
n “Moral imperative…”
n “Radical changes
needed”
Smoking Prevalence (%)
100
90
80
70
60
50
40
30
20
10
0
Gen
Pop
Schizo Depres BiPol
Anx
PTSD
Alc
Drug
Note: General Population includes all categories of mental illness
Healthcare Staff & Culture!
Psychiatrists have higher smoking rates
than other medics and are less likely to
treat nicotine addiction!
Wrong!
Believe MI smokers do not want to quit
Believe they can not quit
Believe quitting would negatively affect
their mental state
Perceiv ed Stres s After Sm ok ing Ces s ation
Cohen &Lic ht ens t ein ( 1990) Healt h Ps y cholo gy ,9:4 66- 478
7. 0
N ever Q ui t or
S tress S core
6. 0
Q ui t 24hrs onl y
5. 0
4. 0
C ont i nuous
3. 0
A bst ai ners
2. 0
Smoki ng
1 mt h
3 mt hs
6 mt hs
Smoking and substance misuse
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Largest cause of preventable death, disease
& health inequalities in the UK
High smoking prevalence previously
demonstrated in substance misusers and
interrelationship e.g.
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Smokers’ subjective symptoms of methadone inadequacy
Smoking impedes cognitive recovery after alcohol abstinence
Smokers require higher doses of some benozodiapines/opiates
Tobacco/cannabis users made fewer attempts to quit and less likely
to successfully quit than tobacco-only smokers
Mortality and morbidity

Smoking may be responsible for much of the
increased mortality of substance misusers
compared with general pop. Eg.
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Cohort study of 845 substance misusers in Minnesota
222 died during study
214 with death certificates: 51% = tobacco-related
death, > than proportion from alcohol & other drugrelated causes (Hurt et al, 1996)
Tobacco & alcohol use multiplies risk of developing
cancers of upper respiratory & digestive tracts (Kalman
et al, 2010; Baca & Yahne, 2009)
NICE recommendations include:
Identifying people who smoke and
offering and arranging support
 Implementing a comprehensive
smoke-free policy including the
grounds
 Support for staff who smoke
 Training for staff

Treatment
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Smoking cessation does NOT impact negatively on
success of abstinence from other substances; may
improve outcomes; continued nicotine dependence may
be a risk factor for relapse
Meta-analysis of 19 RCTs of smoking-cessation
interventions for people in substance misuse treatment
and in recovery showed concurrent treatment of
smoking resulted in a 25% increased likelihood of longterm abstinence from alcohol and illicit drugs
Khara & Okoli, 2011; Burling et al, 2001; Kalman et al, 2010; Baca & Yahne 2009; Williams &
Ziedonis, 2004; Prochaska et al, 2004; Stapleton et al, 2009; Goulay et al, 1994; Moore &
Budney, 2001; Prochaska et al, 2004
Treatment

Smoking cessation programmes
exclusively addressing tobacco less
effective for cannabis users
SLaM audits

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Audit of all computerised client records
across SLaM since 2008 for smoking status
recording, prevalence and offer of support
Audit of addiction wards and community
services in SlaM in 2012-3
Diagnosis
N
Smoking Smokers
Status
Recorded 20-22%
Received
advice to
quit
Received
referral to
smoking
service
34%
(1,103)
64%
(659)
72% (796)
13% (141)
76% (501)
17% (115)
General
Pop.
Depression
26,828
F32/33
Personality
4,621
Disorders F60/61
12% (3,221)
Serious Mental
Illness
F20/25/31
Opiate use
15,954
33% (5,359)
54%
(2,909)
83% (2,439)
22% (656)
6,491
26% (1,700)
71% (1,088)
7.4% (113)
Alcohol use
11,158
15% (1,730)
89%
(1,524)
77%
(1,335)
67% (906)
7.4% (129)
22% (1,023)
Diagnosis
N
Smoking Smokers
Status
Recorded 20-22%
Received
advice to
quit
Received
referral to
smoking
service
34%
(1,103)
64%
(659)
72% (796)
13% (141)
76% (501)
17% (115)
General
Pop.
Depression
26,828
F32/33
Personality
4,621
Disorders F60/61
12% (3,221)
Serious Mental
Illness
F20/25/31
Opiate use
15,954
33% (5,359)
54%
(2,909)
83% (2,439)
22% (656)
6,491
26% (1,700)
71% (1,088)
7.4% (113)
Alcohol use
11,158
15% (1,730)
89%
(1,524)
77%
(1,335)
67% (906)
7.4% (129)
22% (1,023)
Diagnosis
N
Smoking Smokers
Status
Recorded 20-22%
Received
advice to
quit
Received
referral to
smoking
service
34%
(1,103)
64%
(659)
72% (796)
13% (141)
76% (501)
17% (115)
General
Pop.
Depression
26,828
F32/33
Personality
4,621
Disorders F60/61
12% (3,221)
Serious Mental
Illness
F20/25/31
Opiate use
15,954
33% (5,359)
54%
(2,909)
83% (2,439)
22% (656)
6,491
26% (1,700)
71% (1,088)
7.4% (113)
Alcohol use
11,158
15% (1,730)
89%
(1,524)
77%
(1,335)
67% (906)
7.4% (129)
22% (1,023)
SLaM audits


Audit of all computerised client records
across SLaM since 2008 for smoking status
recording, prevalence and offer of support
Audit of addiction wards and community
services in SlaM in 2012-3
Smoking Audit: Method
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Questionnaire survey conducted across Addiction
services in or connected to SLaM
(Blackfriars, Lantern Hall, Beresford Project, Lorraine Hewitt House, AAU, Clouds House, and Ley
Community)
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Staff and client questionnaires to measure:
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smoking behaviour
motivation to quit
treatment provision
attitudes towards nicotine dependence treatment
97% (n=145) and 85% (n=163) response rates
for staff and clients respectively.
Key Findings:
1. High smoking prevalence
Staff
Clients
Ever smoked
70%
(n= 102)
94%
(n= 154)
Currently smoking
45%
(n= 65)
88%
(n= 144)
General Pop. = 20%
(2) Motivated client group
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81% of clients who smoked wanted to give up
23% wanted to in next 3 months
46% wanted to talk to someone about reducing
harmfulness of their smoking; 21% did not know
53% wanted advice on stopping abruptly
77% wanted advice on gradually reducing no. of cigs
smoked
87% wanted info on NRT
>2/3rd of clients did not know enough about varenicline
(Champix) or bupropion (Zyban) to express any interest
3. A Lack of Treatment Provision
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Only 15% clients who smoked had been
offered support during current treatment
episode
56% had never been offered support
Huge unmet clinical challenge
4. Staff and Client Attitudes
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Staff rated nic add. treatment significantly less
important than treatment of other substances
53% staff thought addressing smoking should be put
off until late or after a client’s primary addiction
treatment
Only 29% thought it should be addressed early in
treatment
But nearly half of clients thought it should be
addressed early in treatment
Staff confidence rating for helping client who wanted to
quit = 7 (10 point scale) but varied considerably
Steps being taken
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Assessing evidence on treatment of
smoking and illicit drugs
Improving recording and referrals in line
with new SLaM systems
Reorientation of the Maudsley Specialist
Smokers’ Clinic
Conclusions
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Strong relationship between smoking and use of
other substances
Motivation to stop is apparent but not being
addressed
Need to treat substances concurrently (e.g. Becker et al,
2013)
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Staff who smoke more likely to question importance
of tobacco treatment, so no. of staff smoking is a
concern for their own and patients’ health
Introducing mandatory training and care pathways
within SLaM to address concerns and also NICE
guidance
Harm Reduction for Smoking?
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Nicotine is largely why people smoke
But it’s the other smoke constituents (CO,
tar etc) that cause the death and disease
Rationale for Harm Reduction:
Nicotine Harm Continuum
E-cigs?
NRT
QUIT!
Most
Dangerous
Least
Dangerous
What’s Needed?

Develop clinical pathway to address
the unmet clinical need:
Mandatory recording of smoking status
 Development of routinely provided support
which should be documented in case notes
 Signpost specialist services
 NRT for withdrawal relief available to inpatients
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Clinically Significant Interactions
with Tobacco
Antidepressants
•
•
•
•
•
•
Amitriptyline
Nortriptyline
Imipramine
Clomipramine
Fluvoxamine
Trazodone
Antipsychotics
•
•
•
•
•
Clozapine
Fluphenazine
Haloperidol
Olanzapine
Chlorpromazine
Other Clinically Significant
Interactions with Tobacco
n
n
n
n
n
n
n
n
Heparin
Insulin
Warfarin
Theophylline
Propranolol
Tacrine
Acetaminophen
Caffeine
Recording and Monitoring
What’s needed?
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Develop clinical pathway to address the
unmet clinical need
Staff training:
Support for staff smokers:
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We are doing some qualitative research with
staff to explore high levels of occasional
smoking further
What Can be Done Locally?
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Promote discussion around how your service can
encourage and support smoking cessation
Identify a smoking “champion” on the ward/service
Routinely ask and record clients’ smoking status and
motivation to quit
Inform clients about pharmacological and behavioural
support available as part of standard care and consider
harm reduction for smokers who cannot or will not stop
Identify where clients and staff can get support and clearly
signpost this
Encourage staff to complete relevant training (mandatory?)
Acknowledgements

Camilla Cookson
All colleagues in the services in SLaM who
supported the audit
Karolina Bogdanowicz
Prof John Strang
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Dr Elena Ratschen
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