National Association of Psychiatric Health Systems Teleconference Notes

The following information is a the Position Statement on Smoking Policy and Treatment at State Operated Psychiatric Hospitals.

Silently and insidiously tobacco sales and tobacco smoking became an accepted way of life not only in our society, but also in our public mental health treatment facilities.

Revenue from sales of tobacco provides discretionary income for facilities. Smoke breaks became an “entitlement,” deserved and protected, and are one of the only times consumers can practice relating to each other and staff in a “normalized” way.

When, what, and how much to smoke are often the only choices consumers make as inpatients, reinforcing cigarette use by virtue of the autonomy it appears to allow. More troubling, cigarettes used as positive/negative reinforcement by staff to control consumer behavior.

While taking seriously and treating illicit drug use by those with mental illness for some time, a substance far more deadly and pervasive, and used disproportionately by this population, has largely been ignored. And now, a few words about tobacco. It Kills. And, it kills those with mental illness disproportionately and earlier, as the leading contributor of disease and early death in this population.

A preponderance of evidence has clearly established the deleterious health effects of tobacco smoking and second hand or environmental tobacco smoke. Science as well as experiences in mental health facilities have also shown that tobacco smoking leads to negative outcomes for mental health treatment, the treatment milieu, overall wellness and, ultimately, recovery.

Smoking promotes coercion and violence in facilities among patients and between patients and staff. It occupies a surprising amount of staff and patient’s time that could be better used for more productive activities.

It is a poor substitute for practice in decision-making and relationship building and is inappropriate as a means to manage behavior within the treatment milieu. And, while smoking can be framed as the one – choice consumers get to make while inpatients, and a personal – choice for staff, it is critical to realize that addiction is not a choice. But, quitting smoking is.

While smoking has become more socially unacceptable and prevalence has decreased in the general population, much needs to be done to assist those with mental illness to quit. Currently, 59% of public mental health facilities allow smoking. If we agree that the goal shared by consumer and physician for mental health is recovery and that health and wellness is an integral part of that recovery, the issue of tobacco use in our facilities cannot be ignored.

As individuals committed to supporting health, wellness and recovery, and entrusted with the care and management of consumers and staff in our facilities and of limited public funds, we must act on what we know. Therefore, NASMHPD stands against tobacco and will take assertive steps to stop its use in the public mental health system.

As physicians, we commit to educating individuals about the effects of tobacco and facilitating and supporting their ability to manage their own physical wellness.

We will practice the 5 A’s; ASKING individuals about tobacco use, ADVISING users to quit, ASSESSING their readiness to make a quit attempt, ASSISTING with that attempt and ARRANGING follow-up care.

As administrators, we will commit the leadership and resources necessary to create smoke free systems of care, provide adequate planning, time and training for staff to implement new policies and procedures, and ensure access to adequate and appropriate medical and psychosocial cessation treatment for consumers and staff alike.

As partners in the recovery process, we will work with national organizations and decision makers, public and private service providers, and other support systems to ensure that those who want to be tobacco free have access to continued cessation treatment and support in the community.

Health and wellness is a shared responsibility. NASMHPD is committed to doing their part to assist individuals in going tobacco free and will continue to advocate for those with mental illness in their right and hope to be well in recovery.

Approved by the NASMHPD Membership on July 10, 2006

In a health care system:

• Figure out who smokes
• Educate staff
• Integrate smoking cessation into mental health tx
• Be attentive to co morbidity, make facility smoke-free to protect pts, families, staff

Smoke Free Facilities

50% of psychiatric facilities in the U.S. are now smoke-free, with approx 1 added each month.

SSM Health Care (21 Hospitals in 4 states) became totally smoke free (indoors and outdoors) in 2004.

Outcomes:

• Number of behavioral health outpts identified as non-smokers increased by 20% after 5 months
• Number of behavioral health inpts identified as non-smokers increased by 7%
• Additional inpatient benefits:
• Former smoking areas freed up space for alternate use
• Daily chore of managing pt smoking, arguments about smoke break times and
  access to cigarettes, all disappeared
• Census and pt satisfaction remained stable
• Staff satisfaction increased because all the limit-setting regarding cigarettes was
  no longer an issue
• Pt violence decreased on inpatient units without tobacco available.

From The National Association of Psychiatric Hospital Systems, July, 2007

• The data is simply too compelling re: loss of life and function to continue to ignore the issues of smoking and mental illness any longer. This is a leadership issue as much as a policy and practice issue.
• We must address staff-related smoking prevalence and quitting. Otherwise, culture change will not occur.

Banning smoking in psychiatric hospitals actually reduces mayhem. Facilities that do not allow smoking report fewer incidents of seclusion and restraint and a reduction in coercion and threats among patients and staff.

EMPLOYER BENEFITS of investing in a smoke-free workforce:

• Health care costs are 40% higher for smokers than nonsmokers.
• Smokers are absent from work 26% more often than non-smokers.
• Smokers cost a company drug plan about twice as much as employees who do not smoke.

Additional teleconference notes:

There are approximately 438,000 tobacco-related deaths in the US each year. 44% of all cigarettes smoked are smoked by people who also suffer from mental illness and/or substance abuse. In contrast, only 102,000 will die from drugs and alcohol.

Psychiatric patients who smoke have 7X the heart disease rate and 7X the suicide rate of psychiatric patients who don’t smoke.

One third to one half of mentally ill smokers will die from smoking.

Tobacco companies have targeted poor, mentally ill, minorities with fewer resources. Sub Culture Urban Marketing (SCUM)

The number of cigarettes a person smokes a day directly correlates with an increased lifetime risk of developing Major Depression.

9% (approx. 40,000) of tobacco-related deaths are from second-hand smoke alone. This is nearly as many who die in the U.S. from motor vehicle accidents, and twice as many from drugs (other than alcohol). The Surgeon General’s most recent report states that there is no safe level of exposure to second-hand smoke.

8.6 million people become disabled each year in the US from tobacco.

The smoke, tar, and additives are what kill people. The nicotine just hooks them.

JCAHO is requiring that hospitals and both inpatient and outpt settings be conducive to quitting.

There are 11 PROVEN human carcinogens in tobacco smoke.

Fifty more are not yet proven, but suspected.

None of these are the nicotine itself, but the nicotine is what is addictive.

20.9% of adults smoke in the general population.

75% of those with addictions or mental illness smoke. 70% of people who smoke want to quit, including
the mental health population.

30-35% of the staff in mental health settings smoke.

35% people with panic disorder smoke

49% with depression smoke

80% with EOTH dependence smoke

88% with schizophrenia/bipolar disorder smoke

Depressed smokers have higher suicide rates than depressed non-smokers. People with any psychiatric disorder who smoke have 7X the rate of heart disease AND 7X the suicide rate than similar patients who don’t smoke.

Smokers have greater anxiety and panic than non-smokers. Heavy smoking in adolescence increases risk of later developing agoraphobia, GAD, panic disorder, increased risk of relapse during quit attempt.

Alcoholics have an increased urge to drink when they smell cigarettes.

People with serious mental illness die 25 years earlier than the general population, mostly from smoking, obesity, substance abuse, and inadequate access to medical care.

Smokers with schizophrenia spend more than one-quarter of their total income on cigarettes.

Smoking affects blood levels of psychotropic drugs. It can increase medication metabolism, so higher doses are needed when smoking, with greater potential for adverse effects. Doses may need to be lowered when pts quit, increased if pts start again.

There is increasing evidence that nicotine dependence treatment does not hurt recovery from mental illness or substance abuse and may improve outcomes. A short hospital stay is an opportunity to educate, give tools.

To TX Smoking Cessation and Depression

• NRT (nic replacement therapy) alone is insufficient
• SSRI’s alone have no benefit for smoking cessation but can reduce chance of depression during quit
  attempt, can be combined with Bupropion, NRT, and Varenicline
• Bupropion can be used as monotherapy for both dx’s, can be combined with varenicline, tx may need
  to extend beyond usual 3-6 months.
• Adding CBT has had mixed results.

*Anxiety and Smoking Cessation

• SSRI’s alone have no benefit for smoking cessation but can reduce chance of anxiety or panic during
  quit attempt.
• Bupropion not appropriate as monotherapy, but can be combined with NRT and Varenicline.

PTSD

• Bupropion tolerated and effective

*Alcohol Dependence

• Standard cessation treatments are effective.
• No evidence of increased use of other substances during cessation treatment.
• Alcohol abstinence days are greatest for those who quit smoking.
• Alcoholics who smoke are 10X more likely to develop pancreatitis, have a 3X greater risk of
  cirrhosis,and are at greater risk of severe brain damage associated with alcohol dependence.
  Continued smoking diminishes recuperation from alcohol-related cognitive defecits during alcohol
  abstinence.

*Cessation for Shizophrenia and Bipolar Disorder

• Traditional cessation treatments may be inadequate.
• Harm reduction and NRT
• Hospitalization may be unique opportunities to initiate tx.
• Bupropion can lead to quit rates comparable with general population.
• Quit rates enhanced with CBT
• Overall symptoms not worsened.

Resistance to Smoking Cessation for People with Mental Illness

• Loved ones resist helping them quit
• They feel protective and want to focus on quality, not quantity of life
• But diseases caused by smoking can severely hamper quality as well as quantity of life
• And second-hand smoke imperils loved ones and workers

Barriers to Successful Smoking Cessation

• Provider inattention/pessimism
• Belief that smoking cessation will adversely affect SA/MH tx
• Co-dependency and mental illness
• Mental health staff smoke
• Historic attitudes about smoking in mental health community
• No coverage for cessation drugs
• Improper use of the drugs
• Ignorance of quitlines 1-800-QUIT NOW
• Lack of knowledge or risks/current research
• Centuries-old split between treating the mind “vs.” the body
• Social isolation of the mentally ill
• Recovery from mental illness a relatively new concept
• Historical use of cigarettes as behavior modification/control/reward/distraction/coping in psychiatric
  settings
• Clash of emerging sense of inappropriateness of health care settings encouraging/permitting smoking
• Mental health typically lagging behind other innovations and technologies in health care
• Different agencies, funding, reimbursement (state Medicaid plans reimburse for smoking cessation; most
  private insurers don’t.)
• Historical lack of research data (though current research demonstrates that quitting smoking does NOT
  jeopardize recovery and in fact leads to 25% greater chance of success in recovery)

Benefits From Treating Tobacco Dependence

• Reduced morbity
• 25% greater chance of abstinence from other substances (continued smoking identified as a factor in
  relapse to active substance abuse)
• Reduce financial burden
• Increase self-confidence
• Increase focus on mental health and wellness
• Remember that about half of smokers who want to quit will die from smoking.
• If the cessation rate could increase to even just 10%, 1.2 million additional lives would be saved. No
  other health intervention could make such a huge difference!
• Tobacco use negatively impacts other psychosocial issues that challenge clients in recovery: finances,
  health, HIV status, pregnancy, children’s health, treatment compliance, medications, dealing with
  feelings, social stigma

NEW DEVELOPMENTS
The National Partnership on Wellness and Smoking Cessation
Members:
NAPHS (National Association of Psychiatric Health Systems)
NASMHPD (National Association of State Mental Health Program Directors) See their tool kit “Tobacco
Free Living in Psychiatric Settings
http://www.nasmhpd.org/general_files/publications/NASMHPD.toolkit.FINAL.pdf

NAMI (National Alliance on Mental Illness). Read Position Statement section 7.3
http://www.nami.org/Content/ContentGroups/Policy/Public_Policy_Platform_April_07_marked.pdf
Depression and Bipolar Support Alliance
NASW (National Association of Social Workers)
+ approx. 20 other organizations and growing
Smoking Cessation Leadership Center Mental Health section web site:
http://smokingcessationleadership.ucsf.edu/Presentation07/NASMHPBHealth.pdf

Notes from Sally Caltrider [Retreath Healthcare, Brattleboro, VT]
Conference: July 26, 2007]