From the the first Annual National Conference on Tobacco and Behavioral Health, which occurred May 19-20, 2014 in Bethesda, MD and was hosted by the Central East Addiction Technology Transfer Center (ceattc.org). In the Opening Remarks, leadership from HHS/SAMHSA and SCLC will share their perspectives on where we have been and where we are today in the effort to reduce tobacco use in this country. Focus will be on the importance of reducing use among the population with Behavioral Health issues. Steven Schroeder, MD, Distinguished Professor of Health and Health Care, Division of General Internal Medicine, Department of Medicine, UCSF, where he also heads the Smoking Cessation Leadership Center. The Center, funded by the Robert Wood Johnson Foundation and the American Legacy Foundation, works with leaders of more than 50 American health professional organizations and health care institutions to increase the cessation rate for smokers. It has expanded the types of clinician groups that support cessation, developed an alternative cessation message (Ask, Advise, Refer), created new ways to market toll-free telephone quit lines, and engaged the mental health treatment community the first time. Between 1990 and 2002 he was President and CEO, the Robert Wood Johnson Foundation. During that time the Foundation made grant expenditures of almost $4 billion in pursuit of its mission of improving the health and health care of all Americans. It developed new programs in substance abuse prevention and treatment, care at the end of life, and health insurance expansion for children, among others. Dr. Schroeder graduated with honors from Stanford University and Harvard Medical School , and trained in internal medicine at the Harvard Medical Service of Boston City Hospital and in epidemiology as an EIS Officer of the CDC. He held faculty appointments at Harvard, George Washington, and UCSF. At both George Washington and UCSF he founded medical director of a university-sponsored HMO, and at UCSF he founded its division of general internal medicine. He has published extensively in the fields of clinical medicine, health care financing and organization, prevention, public health, the workforce, and tobacco control. He currently serves as chairman of the International Advisory Committee of the Ben Gurion School of Medicine, is a member of the editorial board of the New England Journal of Medicine, a Director of the James Irvine Foundation, the Charles R. Drew University of Medicine and Science, and the Robina Foundation. He formerly chaired the American Legacy Foundation, was a Council member of the Institute of Medicine, an Overseer of Harvard, and President, the Harvard Medical Alumni Association. He has six honorary doctoral degrees and numerous awards. Schroeder lives in Tiburon, California with his wife Sally, a retired schoolteacher.

1. Tobacco Control should be
a Mainstay of Behavioral
Health
Steven A. Schroeder, MD
National Conference on Tobacco and Behavioral Health
The Smoking Cessation Leadership Center
and Rx for Change
May 19, 2014

2. 1964 Surgeon General Report
on Smoking and Health

3. 50 Years of Tobacco Control
JAMA

4. It’s a New Era

5. Topics for Today
Review history of SCLC
Brief review of harm from tobacco, especially
in Behavioral Health (BH) populations
Brief review of SCLC BH partnerships
A few epidemiology facts
Next steps

6. History of Smoking Cessation
Leadership Center (SCLC)
Story of Robert Wood Johnson Foundation
and tobacco control
Results
--$500 million grant projects, 1990-
2003
--Hailed by Joel Fleishman in “The
Foundation” (2007) as one of 12 high
impact foundation programs of 20th
century

7. Genesis of SCLC
Started at UCSF in 2003 with RWJF grant
Purpose: improve health professionals’
smoking cessation efforts
Knew data re smoking/BH but….
So, initially worked with non-behavioral
health professional groups
Subsequent contract from Legacy
Foundation starting July 2006 for BH

8. How SCLC Does its Work
Identify existing champions and amplify
their voices
Technical assistance
Work with relevant federal and state
agencies
Small grants
Educational offerings: webinars,
conferences, publications, web site
We value flexibility, customer service

9. Facts About Smoking and Health

10. Tobacco’s Deadly Toll
480,000 deaths in the U.S. each year
4.8 million deaths world wide each year
Current trends show >8 million deaths annually by 2030
42,000 deaths in the U.S. due to second-hand
smoke exposure
>16 million in U.S. with smoking related diseases
45.3 million smokers in U.S. (78.4% daily smokers,
averaging 14.6 cigarettes/day, 2012)

11. Flegal JAMA 2005, Mokdad
JAMA 2004
Tobacco: Leading Preventable
Cause of Death
0
50000
100000
150000
200000
250000
300000
350000
400000
450000
Tobacco
O
besity
Alcohol
Infections
Toxins
M
VA
G
uns
AnnualDeathsin
2000

12. Health Consequences of Smoking
U.S. Department of Health and Human Services. The Health Consequences of Smoking: A Report of the Surgeon General, 2010.
Cancers
– Acute myeloid leukemia
– Bladder and kidney
– Cervical
– Colon, liver, pancreas
– Esophageal
– Gastric
– Laryngeal
– Lung
– Oral cavity and pharyngeal
– Prostate (↓survival)
Pulmonary diseases
– Acute (e.g., pneumonia)
– Chronic (e.g., COPD)
– Tuberculosis
Cardiovascular diseases
– Abdominal aortic aneurysm
– Coronary heart disease
– Cerebro-vascular disease
– Peripheral arterial disease
– Type 2 diabetes mellitus
Reproductive effects
– Reduced fertility in women
– Poor pregnancy outcomes (ectopic
pregnancy, congenital anomalies,
low birth weight, preterm delivery)
– Infant mortality; childhood obesity
Other effects: cataract; osteoporosis;
Crohns; periodontitis,; poor surgical
outcomes; Alzheimers; rheumatoid arthritis;
less sleep

13. Never Too Late to Quit*
Age of quitting smoking Years of life saved
25-34 10
35-44 9
45-54 8
55-64 4
* Jha, NEJM Jan 24, 2013

14. Smoking and Mental Illness:
The Heavy Burden
200,000 annual deaths from smoking occur among
patients with CMI and/or substance abuse
This population consumes 40% of all cigarettes sold in
the United States
-- higher prevalence
-- smoke more
-- more likely to smoke down to the butt
People with CMI die earlier than others, and smoking is a
large contributor to that early mortality
Social isolation from smoking compounds the social
stigma

15. Benefits of Tobacco Control in
the Unites States, 1964-2012*
17.7 smoking-related deaths occurred
8 million such deaths prevented
Preventing smoking-related deaths
accounted for 30% of life expectancy
gains during that period!
People with mental illness did not benefit
as much from these declines in smoking
rates **
* Holford ; **Cook : JAMA, 2014

16. SCLC Enters Behavioral Health
Cautiously

17. Individual Champions but
Scanty Organizational Buy-in
Bob Glover, Joe Parks, and National
Association of State Mental Health
Program Directors
Doug Ziedonis and Jill Williams
Chad Morris
Sharon Hall and Jodi Prochaska
Daryl Sharp
Other notables

18. SCLC, Smoking, and BH
Early contacts
--Bob Glover and NASMHPD (smoke
free psych hospital project)
--NAMI
--SAMHSA: Gail Hutchings/Terry Cline
Lansdowne Summit, 2007
Two key arguments: health toll and
exposure to second hand smoke

19. Lansdowne summit, 2007--30 leaders
Objectives
– Raise awareness
– Normalize smoking cessation as part of behavioral health treatment
Core strategies
– Outreach to Key Players and Stakeholders
– Develop Data
– Provide Person-Centered Education/ Embrace Consumer-Driven Process
– Promote Provider-Motivated Education
– Promote Staff Wellness and Smoking Cessation
– Assess and Strengthen the Effectiveness of Quitlines
National Behavioral Health Partnership
for Tobacco Cessation and Wellness

20. The Behavioral Health
Partnership, Lansdowne +
American Legacy Foundation
American Psychiatric Nurses Association
American Psychiatric Association
Association for Behavioral Health and
Wellness
Bazelon Center for Mental Health Law
Behavioral Health Policy Collaborative
California Smokers’ Helpline
Campaign for Mental Health Reform
Carter Center Mental Health Program
Community Anti-Drug Coalitions of America
Depression and Bipolar Support Alliance
Mental Health America
Mental Health Association of Southeastern
PA
National Alliance on Mental Illness
National Association of County Behavioral
Healthcare Directors
National Association of Psychiatric Health
Systems
National Association of Social Workers
National Association of State Mental
Health Program
Directors (NASMHPD)
National Research Institute
National Council of Community
Behavioral Healthcare
National Empowerment Center
Ohio Department of Mental Health
Robert Wood Johnson Foundation
Substance Abuse and Mental Health
Services
Administration/Center for Mental
Health Services
Smoking Cessation Research and
Policy Center at
Oregon Health & Science University
Smoking Cessation Leadership Center
University of California San Francisco
Department of Psychiatry
University of Massachusetts Memorial
Medical Center

21. SCLC Grant Recipients/BH
American Psychiatric Nurse Association
Depression and Bi-Polar Support Alliance
Mental Health America
National Association of State Mental Health Program
Directors (NASMHPD)
National Research Institute (NASMHPD)
National Council for Community Behavioral
Healthcare
University of Colorado at Denver
Community Anti Drug Coalitions of America
National Association of State Alcohol and Drug
National Alliance on Mental Illness (NAMI)

22. Progress
NASMHPD Developed
technical assistance tool kit
addressing how to
implement smoking
cessation in psychiatric
hospital settings
Featured smoking cessation
as a plenary topic during its
recent National Summit of
State Psychiatric Hospital
Superintendents
Promoted 1-800-QUIT NOW

23. National Research Institute
20
41
49
79
0
10
20
30
40
50
60
70
80
90
2005 2006 2008 2011
%SmokeFree%SmokeFree%SmokeFree%SmokeFree
YearYearYearYear
Percent of Smoke Free State Psychiatric Hospitals
*Response rates: 2005 – 55%, 2006 – 82%, 2008 – 75%, 2011 – 80%
Source: Schacht L, Ortiz G, Lane M. Smoking Policies and Practices in State Psychiatric Hospitals 2011. National
Association of State Mental Health Program Directors Research Institute, Inc. Feb 29, 2012.

24. Work with SAMHSA
Created SAMHSA’s Tobacco-
Free Initiative
Trained SAMHSA staff in
Washington
SCLC in-kind technical
assistance to grantees and
states.
Tobacco prevention and
treatment is part of strategic
initiative
24In-Service Training Poster: July 7, 2008

25. 100 Pioneers for Smoking Cessation
(2009)
Phase 1: $1,000 + SCLC TA to grantees for
smoking cessation and smoke-free facilities
Phase 1 raised rates of cessation intervention
from 20% to 50%
Phase 2, 2010: 25 sites got additional $2,000
for program expansion
Key was identification and support of existing BH
programs

26. Purpose: launch state-wide
collaborative among behavioral
health providers, consumers,
public health groups, and other
stakeholders to create and
implement action plans to reduce
smoking prevalence among
behavioral health consumers and
staff and foster smoke-free living.
Each set a goal to reduce smoking
prevalence in MH and SA in 3-5
years time.
2010
– New York
2011
– Arizona
– Oklahoma
– Maryland
– North Carolina
2012
– Texas
– Arkansas
2013
– Mississippi
SAMHSA Leadership Academies for Wellness
Wellness and Smoking Cessation
26

27. SAMHSA PARTNERSHIP
Represents over 38 states,
Blue flags = Phase I Pioneers
Yellow flags = Phase II Pioneers , Pink flags = Academy States (NY, AZ, OK, MD, NC, TX, AR)27

28. AJPH Article, May 2014
Source: Santhosh L, Meriwether M, Saucedo C, Reyes R, Cheng C, Clark B, Tipperman D. From the Sidelines to the Frontline: How the Substance
Abuse and Mental Health Services Administration Embraced Smoking Cessation. Am J Pub Health 2014; 104(5): 796-802.

29. Online, interactive,
educational initiative
promoting the idea of
wellness in both mind
and body
Smoking not in 1999
version
Healthy eating, exercise,
smoking & substance
abuse
Consumer success stories

30. Nation’s leading drug abuse prevention organization
5,000 community anti-drug coalitions in the country.
Survey indicates tobacco is 3rd priority
– 59% of Coalitions are addressing tobacco directly
– 35% are directly involved or connected to another
collaborative addressing smoking cessation
– 77% collect data on tobacco
Collaborating with SCLC on a CTG National Networks
Dissemination project
Workshops, webinars, materials created and shared

31. Behavioral Health Advisory Forum
Screening and Training
NAQC standard optional question(s) for the Minimal Data
Set*
– Do you have any mental health issues or emotional
challenges, such as an anxiety disorder, depression
disorder, bipolar disorder, alcohol/drug abuse, or
schizophrenia?
– Do you believe that these mental health issues or
emotional challenges will interfere with your ability to
quit?
Developed a standardized training curriculum for quitline
tobacco treatment specialists
* Do Quitlines Have a Role in Serving the Tobacco Cessation Needs of Persons with Mental Illnesses
and Substance Use Disorders? The Behavioral Health Advisory Forum (BHAF), Background Report,
September 2010.

32. APNA Addresses Smoking
Special issue of JAPNA (Feb/March 2009)
devoted to smoking
APNA adopts policy statement:
All nurses working with BH populations:
--demonstrate smoking cessation
competencies
--Intervene in the practice settings
--Act to change attitudinal, institutional and
organizational barriers to improve cessation

33. APNA Smoking Cessation
Policies (cont)
--Take action at state level through APNA
chapters
--Advocate for policy and system-wide
changes
--Expand smoking cessation education
--Increase each year by 5% # psych nurses
who refer smokers to treatment
--Increase each year by 5% # who provide
cessation best practices

34. APNA as Lonely Pioneer, to Date
No other BH health professional organization
has yet adopted similar policies!

36. Federal Agencies now Acknowledge BH
population in Smoking Cessation Efforts
CDC
SAMHSA
ASH
? HRSA
Can’t achieve tobacco control goals without
attention to behavioral health!

37. Vision for Smoking and BH
All organizations representing BH clinicians
and consumers designate smoking
cessation as highest priority
All BH clinicians either directly intervene or
refer to appropriate resource
All relevant federal, state, and local
governmental organizations assure access
to smoking cessation for BH, smoke-free
grounds, and non-smoking staff