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Developing the evidence base for an intervention to address tobacco and cannabis use tcs 3 2019

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Why tobacco and cannabis? High smoking rates amongst those with SUD (Guydish et al, 2016)
Used together but clinically separated
Unintended consequence of tobacco addiction
Poorer cessation outcomes for co-users (Peters et al, 2012)
Increasing concern about impact of cannabis use; potency increased (EMCDDA, 2018, Freeman et al 2018, 2019)
Unique, complex relationship

Published in: Health & Medicine
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Developing the evidence base for an intervention to address tobacco and cannabis use tcs 3 2019

  1. 1. Developing the evidence base for an intervention to address tobacco and cannabis use HANNAH WALSH PHD STUDENT, MENTAL HEALTH NURSE INSTITUT CATALA D’ONCOLOGIA, BARCELONA 18TH MARCH 2019
  2. 2. Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care Supervisors: Dr Maria Jose Duaso Lecturer, Adult Nursing Professor Ann McNeill Professor of Tobacco Addiction, National Addictions Centre, Institute of Psychiatry, Psychology and Neuroscience
  3. 3. Plan for today 1. Rationale for my PhD study – motivations, questions, hypotheses 2. Background: tobacco and cannabis use in the UK and Spain 3. Systematic review findings 4. Preliminary survey findings 5. Next steps
  4. 4. Why tobacco and cannabis? High smoking rates amongst those with SUD (Guydish et al, 2016) Used together but clinically separated Unintended consequence of tobacco addiction Poorer cessation outcomes for co-users (Peters et al, 2012) Increasing concern about impact of cannabis use; potency increased (EMCDDA, 2018, Freeman et al 2018, 2019) Unique, complex relationship
  5. 5. Cannabis, THC and CBD Hash, resin, hashish High potency, ‘skunk’ THC and CBD
  6. 6. Harms associated with cannabis use Acute: ◦ Impaired attention, memory, psychomotor performance ◦ increased risk of road traffic accidents ◦ Increased risk of psychosis Most likely chronic effects: ◦ dependence (1 in 10 users) ◦ subtle cognitive impairment ◦ pulmonary disease and respiratory symptoms ◦ malignancy of the oropharynx Adolescent cannabis use: ◦ impaired personal and educational attainment ◦ higher rates of truancy, delinquency, criminality, higher rates of other substance misuse, lower employment ◦ potential exacerbation of mental health conditions such as anxiety, depression and psychotic disorders Winstock et al, 2010
  7. 7. Cannabis use across Europe in young adults EMCDDA data, 2018
  8. 8. UK treatment services Tobacco cessation: ◦ Stop Smoking Services, funded by Public Health England ◦ Behavioural treatment + NRT ◦ Specialist stop smoking services for those with mental health problems, pregnant women ◦ Free NRT prescriptions for all on social security benefits Cannabis use disorder ◦ Substance use disorder treatment provided by third sector ◦ Most services focus on other substance use, i.e. heroin or alcohol dependence ◦ 2.3% of UK population report CUD; but only 14.6% of these ever accessed treatment (McManus 2014)
  9. 9. Tobacco and cannabis: a unique relationship psychological physiological (co) dependence How do these factors influence quitting either, or both?
  10. 10. Doctoal thesis: Aims To describe profiles of co-smokers, co- quitters and trying-to-quitters To build up the evidence and background theory to support an intervention To develop a logic model for an intervention which addresses both tobacco and cannabis
  11. 11. Who and what to target? Tobacco treatment seekers? Cannabis treatment seekers? Treatment seekers or general population? What age? Where?
  12. 12. Medical Research Council complex intervention development framework Carry out a systematic review of interventions which address both substances To carry out a questionnaire survey to ascertain patterns of co- smoking, motivation to quit, history of quit attempts, potential sources of support for quitting - To carry out qualitative interviews with co-smokers, to further explore similar questions as above -Develop a logic model for an intervention to address both tobacco and cannabis -COM-B used for development of survey questions and qualitative interviews
  13. 13. Systematic review & meta-analysis Aims: To identify studies reporting on interventions addressing tobacco and/or cannabis use, and reporting on change in use of both substances post intervention Methods: 5 databases were searched between 1990 and 2018, to identify intervention studies which either;​ - Targeted both tobacco and cannabis use (including multi-substance interventions) OR​ - Targeted either tobacco or cannabis use, but which reported on use of both pre and post intervention​ RCTs, feasibility and pilot studies were included.​ Data were also collected from some authors (n=13) on sample of co-users at baseline only. Raw or analysed data were provided by authors. Outcome measures: Tobacco and cannabis reduction and cessation rates for CO-USERS ONLY were extracted
  14. 14. Results (preliminary, not peer reviewed) 20 studies were found; 12 RCTs, 8 pilot or feasibility studies, mostly US ◦ Cannabis focus = 7 ◦ Dual focus = 6 ◦ Multi-substance interventions = 6 ◦ Tobacco focus =1 ◦ Dual studies: ◦ Appear feasible ◦ Becker 2015: used a group format; included motivation intervention prior to treatment intervention, dual abstinence = 7% at 6 months
  15. 15. Meta-analyses (preliminary, not peer reviewed)
  16. 16. SR and MA conclusions (preliminary, not peer reviewed) 1. Interventions targeting either cannabis, tobacco or multi-substance interventions have minimal or no effect on tobacco or cannabis cessation; little difference seen between target of intervention. Some effect on cannabis reduction noted. Further research is required to disentangle the potential reasons why outcomes for co-users appear poor. 2. Dual interventions demonstrate feasibility; motivation may be an issue 3. Measurement outcomes require attention – variety across measurement of cannabis, and differences between tobacco and cannabis measurement
  17. 17. Survey of co-use and “co-quitting” •3 FE colleges distributed online survey by email; 150 responses so far •Age range 16-30; most aged 16-19 •Invited to participate if current or recent tobacco AND cannabis user •Detailed questions on tobacco, cannabis use; tobacco and cannabis quit motivation and quit attempts; ◦ 41% daily tobacco users, 22% daily cannabis users ◦ 78% reported joints as most common ROA ◦ 8% quit both; 13% tried to quit both ◦ 21% tried to stop tobacco; 3% tried to stop cannabis ◦ 63% reported some motivation to quit tobacco; only 19% reported some motivation to quit cannabis
  18. 18. Qualitative interviews Who do you know who has quit tobacco or cannabis? What would influence you to quit smoking tobacco or cannabis? Michie et al, 2011
  19. 19. Logic model example: capability, opportunity, motivation What behaviour am I trying to change? SR: Dual studies focus on motivation Existing theory of behaviour change- COM-B Survey: e.g. motivation to quit tobacco higher Qualitative: e.g. unaware sources of support e.g. Ensure access to NRT
  20. 20. Thank you for listening Hannah.walsh@kcl.ac.uk @hannaheawalsh
  21. 21. References European Monitoring Centre for Drugs and Drug Addiction (2018), European Drug Report 2018: Trends and Developments, Publications Office of the European Union, Luxembourg. Freeman, T. P., Groshkova, T., Cunningham, A., Sedefov, R., Griffiths, P., and Lynskey, M. T. ( 2019)Increasing potency and price of cannabis in Europe, 2006–16. Addiction, https://doi.org/10.1111/add.14525. Freeman, T., Van der Pol, P., Kuijpers, W., Wisselink, J., Das, R., Rigter, S., . . . Lynskey, M. (2018). Changes in cannabis potency and first-time admissions to drug treatment: A 16-year study in the Netherlands. Psychological Medicine, 48(14), 2346-2352. doi:10.1017/S0033291717003877 Guydish, J., Passalacqua, E., Pagano, A., Martínez, C., Le, T., Chun, J., Tajima, B., Docto, L., Garina, D., and Delucchi, K. ( 2016) An international systematic review of smoking prevalence in addiction treatment. Addiction, 111: 220– 230. doi: 10.1111/add.13099. McManus S, Bebbington P, Jenkins R, Brugha T. (eds.) (2016) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6:42. Published 2011 Apr 23. doi:10.1186/1748-5908-6-42 Peters, E. N., Budney, A. J. and Carroll, K. M. (2012), Clinical correlates of co‐occurring cannabis and tobacco use: a systematic review. Addiction, 107: 1404-1417. doi:10.1111/j.1360-0443.2012.03843.x Winstock Adam R, Ford Chris, Witton John. Assessment and management of cannabis use disorders in primary care BMJ 2010; 340 :c1571

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