Transcript Smokers and Mental Illness: Forgotten Population in the

Smokers and Mental Illness:
Forgotten Population in the
Tobacco Wars?
William Collinge, Ph.D. & Tom McLaughlin, Ph.D.(c)
Univ. New England/Spurwink Center for Research
Portland, Maine
Sherry Sabo, Ph.D.
Counseling Services, Inc., Saco, Maine
I.
People with severe mental
illness smoke at twice the rate
of the general population

Nationally 22.8% of adults smoke
(CDC/MMWR, 10/10/03, 52(40):953-6)

20.4% of Maine adults are current
everyday smokers (1 pack per day).
(Maine Bureau of Health, Maine Tobacco Survey, 2000)

Estimates of the smoking rate for
people with severe mental illness
range from 50-90%.
(Hansen et al., 2001. British J Psychiatry, 179:5,
438-43)

62% of outpatient clients at
Counseling Services, Inc.
(community mental health center)
smoke one pack or more per day.
(UNE/Spurwink Center for Research/CSI joint
project)

People diagnosed with mental illness
consume nearly 45% of cigarettes
smoked in the US.
(Lasser et al., 2000. JAMA, 284: 2606-10.)

Heaviest smokers are known to have started
smoking prior to their first diagnosis of
severe mental illness.
(Mass. Dept. of Mental Health, 2000. The Mortality
Report: 1998-9)

Heaviest smokers are most likely to have
accumulated more than one psychiatric
diagnosis.
(Kelly & McCreadle, 1999. Am J Psychiatry,
156:11, 1751-7)

The general decline in smoking
prevalence rates has been least marked
among the most deprived members of
society, and over time this group has
come to form an increasing proportion
of those who remain smokers.
(Jarvis & Wardle, 1999. In Marmot &
Wilkinson, Social Determinants of Health,
Oxford U Press)

Widening social class inequalities in
terms of smoking prevalence rates
suggest that members of lower social
classes are increasingly more likely to
take up smoking and less likely to
quit.
(Evandrou et al., 2002. Health Stat Q, 14:30-8)
II.
Clinical experience indicates that
conventional smoking cessation
approaches are ineffective with
this population.

Problems:
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Failure to attend
Dropping out
Relapsing
Erroneous use of aids (patch, gum, etc.)
Interactions with medication

“Psychological” explanations
– Low ego strength to endure change
– Low motivation to quit
– Poor executive functioning

“Lay epidemiology”
The common failure of smoking cessation
programs in deprived populations is due to
health professionals’ failure to understand
the exigencies of everyday life of people
struggling to live at society’s margins.
(Lawlor et al., 2003. Smoking and Ill Health:
Does lay epidemiology explain the failure of
smoking cessation programs among deprived
populations? Am J Pub H, 93(2).)

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“Persistent smoking among the most
deprived members of society may represent a
rational response to their life chances
informed by lay epidemiology.”
“Health promotion initiatives designed to
reduce smoking among members of these
groups may continue to fail unless the
general health and life changes of such
individuals are first improved.”
(Lawlor et al., 2003)

“Poor housing conditions, occupational
hazards, and environmental dangers are
more immediate threats to the health of
those in lower socioeconomic positions
than is smoking. Smoking cessation
may become a priority only when these
other hazards have been reduced.”
(Lawlor et al., 2003)

Attention to smoking cessation and to
self-management for other health
conditions most likely will not occur
until other areas of their lives are
understood and efforts made to
increase patients’ control over
elements of their own lives.
III.
The higher rates of smokingrelated illnesses and mortality
in the mentally ill are largely
unrecognized or
unacknowledged.

Smoking-related fatalities are
significantly higher in people with
schizophrenia than in the general
population.
(Brown et al., 2000. Br J Psychiatry, 177: 212217)
Factors preventing people
with mental illness from
receiving good medical care
Less likely to report physical
symptoms spontaneously.
 Cognitive impairment, social
isolation, or suspicion may contribute
to patients not seeking care, or
adhering to treatment.

Lack of social skills when presenting
for care.
 Stigma of mental illness.
 The fragmented healthcare system.
 Difficulties in accessing care.

(Jeste et al., 1996. Schiz Bull 22:413-27; Goldman,
1999. J Clin Psych, 60 (suppl 21):10-5)
IV.
Creating change in service
delivery requires a systems
approach involving
transforming fundamental data
collection about clients,
tracking data flow, and
confronting obstacles in the
organization's culture.
The UNE/CSI Partnership
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Data collection
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Clients
Staff
Focus groups
Record reviews
V.
A population-specific, clientdirected approach can be
developed to create appropriate
intervention strategies.
The Client Consultant Project
Hired CSI clients as consultants
 Ten-week series of meetings
 Explored the “lay epidemiology” of
chronically mentally ill people who
smoke
 Developed a client-driven model of
intervention specific to this population

VI.
To include these strategies
within the changing
organizational culture of the
mental health setting requires a
special type of collaborative
model
Elements of a
Collaborative Approach
(Von Korff M et al. (1997). Collaborative
Management of Chronic Illness. Ann Int
Med, 127:7, 1097-1102)

Collaborative definition of problems:
– Patient-defined problems are identified
along with medical problems diagnosed by
physicians
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Targeting, goal-setting and
planning:
– Patients and providers focus on a
specific problem, set realistic
objectives, and develop an action plan
for attaining those objectives in the
context of patient preferences and
readiness

Creation of a continuum of selfmanagement training and support
services:
– Patients have access to services that
teach skills needed to carry out
medical regimens, guide health
behavior changes, and provide
emotional support
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Active and sustained follow-up:
– Patients are contacted at specified
intervals to monitor health status,
identify potential complications, and
check and reinforce progress in
implementing the care plan.
The Collaborative Care
Project
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Joint project between CSI and the
UNE/Spurwink Center for Research
Based at University Health Care,
University of New England
Nurse Practitioner and Social Worker
Collaboration between client, project
staff, and CSI staff
Development of a Personal Plan for
Health
Personal Plan for Health
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My personal health goal(s) and target date(s)
Personal rewards I look forward to after
reaching my goal(s)
Action steps needed to reach my goal(s)
Strengths I have that will help me reach my
goal(s)
Other resources & support I need to reach my
goal(s)
Obstacles or challenges I might face in
reaching my goal(s)
Long-Term Vision
Sustainability
 Incorporate lay epidemiology in
understanding the needs of
participants
 Empower participants as members of
the collaborative care team

Finis