Transcript INTEGRATING TOBACCO CESSATION INTO ADDICTION …

INTEGRATING TOBACCO
TREATMENT INTO ADDICTION
SERVICES
Mike DeVillaer
Provincial Services, CAMH
Department of Psychiatry & Behavioural
Neurosciences, McMaster University
Addictions Ontario Conference
May 31 2011
Coordinating Team
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Mike DeVillaer, Provincial Services, CAMH
Peter Selby, Addictions Program, CAMH
Barney Savage, Public Policy, CAMH
JF Crepault, Public Policy, CAMH
Norma Medulun, Addictions Ontario
Ian Stewart, Ontario Federation of Community
Mental Health and Addiction Programs
Survey Research Associate: Natalie MacLeod,
CAMH
Project Partner: ConnexOntario
Funding
The CAN-ADAPTT Project
Tobacco Control Programme
Health Canada
Buy In ?
Economic Costs of Drug Problems in
Ontario,
2002 = $14,300 million
Illicit Drugs
20.4%
Tobacco
42.4%
Alcohol
37.2%
Rhem et. al. (2006) The Costs of Substance Abuse in Canada
in 2002. Canadian Centre on Substance Abuse.
1.3+ Million Alcohol-, Tobacco- &
Illegal Drug-Related Hospital Days,
Ontario 2002
17.8% of all hospital days
80
%
60
58.8
33.1
40
20
8.1
0
Smoking
Alcohol
Illegal Drugs
Rehm J. et.al. (2006). The Costs of Substance Abuse in Canada, 2002.
Canadian Centre on Substance Abuse.
Drug-related Deaths in Ontario (2002)
All deaths = 82,234
Drug-related
19%
Other
81%
Rehm J. et.al. (2006). The Costs of Substance Abuse in Canada, 2002. Canadian
Centre on Substance Abuse.
Type of Drug-related Deaths
in Ontario (2002)
Drug-related deaths = 15,253
Alcohol 9.1%
Illegal Drugs,
4.2%
Tobacco,
86.2%
Rehm J. et.al. (2006). The Costs of Substance Abuse in Canada, 2002. Canadian
Centre on Substance Abuse.
From the General Population to the
Addiction Treatment Population
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more addiction treatment clients die from
tobacco-related disease than from all other
causes combined (Hurt et al.,1996)
The Provocative Question
Is Ontario’s addiction treatment
system saving people from the perils
of other drugs so they can die from
their use of tobacco ?
Smoking Prevalence in Addiction
Treatment
US median across all studies: 76.3%
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For any single year:
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Lowest: 65.0%
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Highest: 87.2%
(J. Guydish, et. al., 2011)
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Ontario DATIS (2009-10): 46.4%
High Demand
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2009-10: 22,775 clients identified tobacco
as a problem substance (DATIS, 2010)
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third highest, behind alcohol and cannabis
Problem Drugs Identified by People in Drug
Treatment Programs in Ontario, 2009-10
68.8
Alcohol
Cannabis
32.6
21.7
Tobacco
Presc. Opioids
18.2
Cocaine
17.1
Crack
16.5
3.6
Benzodiazepines
Ecstacy
2.4
Heroin/Opium
2.3
0
10
20
30
40
50
% of Clients
CAMH: DATIS Database May 2010; n =104,954
60
70
80
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Our clients know that tobacco is
harming them, and they are telling
us so
It Makes a Difference
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Non-smoking clients in addiction treatment
programs have better outcomes than those who
continue to smoke (McCarthy et. al., 2002; Satre
et. al.,2007)
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when we help our clients quit smoking we
improve their overall health
may also improve their outcomes for other drug
problems
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Nova Scotia, Canada
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Ministry of Health-funded addiction
treatment programs are mandated to
provide tobacco treatment to those clients
who want it
Ontario Addiction Treatment Policy Arena
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Ontario Ministry of Health’s “Setting The Course: A
Framework for Integrating Addiction Treatment Services
In Ontario” (1999) did not include the words ‘tobacco’ or
‘smoking’
2010: MH&LTC released Report of the Minister’s
Advisory Group on the 10-Year Mental Health and
Addictions Strategy
the words tobacco & smoking do not appear
In contrast, alcohol has lots of mentions
Bottom Line
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deaths
hospitalization
economic costs
treatment outcomes
health status
tobacco one of our biggest drug problems
maybe the biggest
Why not recognized ?
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not as much highly visible behavioural or
social disruption
no personal crises requiring urgent
attention
serious physical harm occurs later in life
manifested in hidden settings of hospital
wards & home confinement
The Necessary Questions
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Do you smoke tobacco ?
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Would you like some help to quit ?
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At minimum, a referral…
An Integration Issue
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integrating addictions & mental health
integrate treatment of all addictions ?
major theme in the Ministry’s proposed 10
year strategy
highlighted in letter of transmittal to the
Minister
“We are recommending more integrated
services that will make better use of
existing skills and resources.”
So what do we do about it ?
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CAMH Tobacco Policy Group 2008
Workgroup comprised of representatives from:
 Addictions Ontario
 CAMH
 Ontario Federation of Community Mental Health
& Addiction Programs
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ConnexOntario
Field Consultation, March 2009
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Invitation sent to addiction providers in members of
Addictions Ontario & Ontario Federation of Community
Mental Health and Addiction Programs
34 addiction service providers: front-line & mgt
Purpose: identify, for clients, counsellors & programs,
the benefits, hurdles & solutions for integrating tobacco
treatment
Participant feedback was very positive
Full report sent to all member agencies of AO &
Federation & available at camh.net
Benefits for Clients
Improved health and quality of life
Convenience of one program
addressing all addiction issues
Quitting smoking reduces risk for
relapse to other drug use
Clients
Hurdles
Smoking: cope with anger,
fear, stress & loneliness
Smoking counsellors may
provide triggers for clients
Contraband cigarettes are
cheap
Clients more motivated to
deal with crises in their lives
Solutions
Nicotine replacement; identify
alternate coping mechanisms
Ideally staff would be nonsmokers; supported to quit
Explore clients’ finances; even
cheap smokes aren’t that
cheap
Benefits for Counsellors
Generic clinical knowledge &
skills apply to tobacco treatment
Nicotine replacement is a
powerful tool they can use
Smoking counsellors can quit;
improve their own health
Counsellors
Hurdles
Over-worked, so unable to
offer tobacco treatment
groups
Some staff use cigarettes to
reward client progress in
treatment
Clients may not self-identify
as nicotine addicts
Solutions
Attitude shift important for
clients & staff
Counsellors take the
initiative to prompt
Benefits for Programs
Engagement in best practices for
addictions treatment
Normalizes non-smoking; communicates
a consistent professional health
promotion message
Decreased relapse rate should shorten
wait lists
Programs
Hurdles
Solutions
Cost of training staff
Cost of nicotine replacement Use budget surplus to
products
stockpile NRT
Additional funding required
Business case re: long-term
health care savings
Perception that tobacco is
Education - TEACH
not an addiction, so people
can quit on their own
Adding a smoking cessation
component requires a
cultural shift at programs
Early adopters have some
good advice for us
Survey the Field
Two Questions:
1) Provide tobacco treatment ? (yes/no)
2) If no, what are the barriers ?
Option: comments
Survey Distribution
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email to members of AO & OFCMHAP
183 organizations operating 1395 programs
emailed again 10 days later
phone call to non-responders a week later
all organizations were phoned 2 or 3 times
CAMH’s Provincial Services followed up with
some non-respondents in their respective
communities
Survey closed May 2010
Full & summary reports: camh.net
Results: Response Rate
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1130 programs run by 132 organizations
responded
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81.0% of programs
72.1% of organizations
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Results: Prevalence of Tobacco
Treatment in Addiction Services
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tobacco treatment provided by 266
programs operated by 31 organizations
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23.5% of programs
23.5% of organizations
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Results: Barriers
Organized by 3 implementation strategies:
1) Increase Awareness (18.0 % of barriers)
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not important to clients
clients need smoking to cope with problems
not as important as other issues
jeopardize other treatment goals
too dramatic of a change for program’s culture
increase program wait times
Results: Barriers (cont’d)
2) Mandate Renewal (28.6 % of barriers)
 no formal mandate from funder
(MoH&LTC)
3) Resources (53.2% of barriers)
 staff training
 stop-smoking medication
 adequate staffing levels
So, where are we ?
Big problem
 No easy solution
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Give up ?
“When I read about the
evils of drinking, I gave up
reading.”
Henny Youngman
Why Are Alcohol & Tobacco Our
Biggest Problems?
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legal
aggressively & seductively marketed to
people
not just allowed, but encouraged
Lifestyle Ads
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2 ads
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2 brands
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2 types of
men
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2 market
segments
Dakota: R.J. Reynolds Tobacco
Company, 1990
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marketing
campaign for a
new cigarette
brand
targeted young,
poorly educated,
white women
"virile females"
leaked to the
Washington Post
Details in Leaked Document
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target: women with no education beyond high school
women whose favourite pastimes included "cruising",
"partying", attending "Hot Rod shows", & "tractor pulls"
with their boyfriends
favourite television roles are "evening soap opera
bitches“
spend her free time "with her boyfriend doing whatever
he is doing“
chief aspiration is "to get married in her early twenties"
Common Themes in Tobacco
Advertising
1) athletics: athletic male
wearing a basketball jersey
and baseball cap
2) nicotine as appetite
suppressant
 a woman who might wish to
lose some weight
 large confection suggests
dieting may not be working
 "lights", low calorie food
products
3) romance: 'sweetheart'
suggests that there may be a
romantic encounter looming
Market Uptake ?
Tobacco Control, Summer 1998:
 prior to the start of the Joe Camel campaign, Camel’s
share of the youth market (ages 12-17) was less than
1%
 year and a half later, it had risen to 8%
 by 1993, had climbed to 13%.
U.S. Centre for Disease Control, October, 1998:
 73% increase in the number of American teens who
became daily smokers since the debut of the Joe Camel
ad campaign in 1988
Marketing Memorandum, stamped
"RJR Secret", 1997
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"To ensure increased and
longer term growth of
Camel Filter, the brand
must increase its share of
penetration among the
14-24 age group which
have a new set of liberal
values and which
represent tomorrow's
cigarette business."
But publicly…
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R.J. Reynolds 1994 statement:
“…that smoking is a choice for adults and
that marketing programs are directed at
those above the age to smoke."
Markets & Clients
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Just as a market has segments –
So does the population of tobacco smokers
They are not all the same
Many of those who continue to smoke may be
very different from those who have quit
Public Health Tobacco Strategy
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The strategies that have brought us
unprecedented declines in smoking
rates may not be the same strategies
that will appeal to those who continue to
smoke
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We will need new strategies
Tobacco Industry
What strategies do we use to make sure that
current smokers do not join the majority of
non-smokers ?
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As before, they will focus on the vulnerable –
your clients
3-4 x more likely to smoke than the general
population
Tobacco Industry & Vulnerable
Market Segments
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not social needs but personal psychological
needs:
stress relief
behavioral arousal
performance enhancement
obesity reduction
(Le Cook et. al, 2003)
We need your help …
… to protect your clients
from the tobacco industry
Progress,
Setbacks
&
Next Steps
Progress: Modest but Encouraging
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programs providing tobacco treatment are now
identified as such in DART database
Connex staff can search their database
client search on DART website coming
Connex provides annual updates to reflect
progress
One Year Later:
Are more programs integrating tobacco ?
Survey Baseline (May 2010):
23.5%
ConnexOntario Update (May 2011)
 Programs:
23.9%
 Organizations: 24.2%
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barriers are very real
What are we doing about the
barriers identified in our survey ?
Increase Awareness
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Making Gains
Two CAMH in the Community events
National tobacco conferences
McMaster research day
AO Conference
Mandate Renewal
Communication strategy being developed:
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LHINs
Ministry
Needed Resources
Funding proposal being prepared for Ministry:
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increased awareness (OTN session)
meeting of addiction treatment organizations
currently providing tobacco treatment
training in tobacco treatment (TEACH)
support for community of practice
access to stop-smoking medications
improved staffing capacity
System transformation
takes
a
long
time …
But…
Read our reports:
www.camh.net/Public_policy/index.html
Additional information:
[email protected]