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, a program of The Danya Institute. You can see videos from the conference on our website www.ceattc.org (go to “Tobacco and Behavioral Health Resources” under “Special Topics”). Having peers who have succeeded in recovering from tobacco dependence talk to smokers with mental illness offers advantages. Advantages of using peer counselors include reduced language and cultural barriers, increased trust and lowered defenses, and low cost. Peer counselors are often rated highly by other consumers and there is an added benefit in the modeling that comes from seeing peers do well and return to work. We have promoted community based advocacy and education through the CHOICES Program (Consumers Helping Others Improve their Condition by Ending Smoking). CHOICES employs mental health peer counselors known as Consumer Tobacco Advocates (CTA) to deliver the vital message to smokers with mental illness that addressing tobacco use is important and to motivate them to seek treatment. The philosophy of CHOICES is to bring information to smokers with mental illness about the harm of tobacco, as well as the benefits of quitting and possibilities of treatment. Additional goals are to enhance advocacy and education about addressing tobacco in mental health treatment settings through strong partnerships with a consumer advocacy organization (Mental Health America) and state government (New Jersey Division of Mental Health Services). Participants will be able to: - Understand the benefits of using peer counselors to disseminate health education information and increase demand for tobacco services - Examine existing community relationships and partnerships that will help promote culture change in mental health systems. - Understand how materials like newsletters and websites increase the reach of peer counselors - Become familiar with CHOICES, a peer delivered tobacco dependence education and intervention program in New Jersey

2. Smokers with MI or SMI
Reduced Quitting over Lifetime
Mental Illness (MI) = anxiety, MDE, PTSD, psychoses, bipolar, drug dependence
Serious Mental Illness (SMI)= measured by K6
Hagman 2007; McClave 2010; Lasser 2000; Pratt & Brody 2010
FormerSmokers(%)
E= N x S
Exsmokers =(number trying to quit) x (success of attempts)
R West, 2013

3. Smokers with Depression
Less Likely to Quit
fewer former smokers

4. Smoking Cessation in
Outpatient SA treatment
• Part of CTN, included methadone sites
• N=225 smokers
SC adjunct or treatment‐as‐usual (TAU)
9 weeks group counseling plus NP
• No difference in SC vs TAU
–on rates of retention in SA tx
–abstinence from primary substance
–craving for primary substance.
Reid et al., 2008

5. Heaviness of Smoking
Index=
Measure of Dependence
Number of cigarettes per day (cpd)
AM Time to first cigarette (TTFC)
≤ 30 minutes = moderate
≤ 5 minutes = severe
Heatherton 1991

6. Smokers with Depression
Smoke More CPD & Are
More Dependent

7. Greater Nicotine Dependence in
Serious Psychological Distress
0
10
20
30
40
50
60
70
NDSS TTFC 5 Mins TTFC 30 Mins
SPD
no
SPD
%
2002 National Survey on Drug Use and Health; Hagman et al., 2008
SPD= Estimate of Serious Mental Illness

8. Smokers in Addiction Treatment
Moderately to Severely Addicted
to Nicotine
N=1882 smokers in NJ addictions treatment, 2001-2002;
Williams et al., 2005

9. Williams et al., NTR 2010
Individuals with Schizophrenia
Highly Addicted
4 minute Nicotine Boost (ng/mL)
25.2 vs. 11.1 ; p<0.01
Greater nicotine intake per cigarette

10. Tobacco Withdrawal
Emerge hours after last cigarette
Can last for (4) weeks
Depressed mood
Insomnia
Irritability, frustration or anger
Anxiety
Difficulty concentrating
Restlessness
Increased appetite or weight gain
DSM-5

11. Reduced Success Quitting in
Smokers with Anxiety
Disorders
panic, social anxiety or GAD
More withdrawal
symptoms
Piper et al., 2010

12. NRT and Agitation
in Smokers w/Schizophrenia:
• 40 smokers in psych ER
• 21mg patch vs placebo patch
• Usual care for psychosis
• Agitated Behavior was 33% less at 4
hours and 23% lower at 24 hours for
NRT group
• Better response in lower dependence
• Same magnitude of response as
antipsychotic studies Allen 2011; Am J Psych

13. READINESS to QUIT in SPECIAL
POPULATIONS
* No relationship between psychiatric symptom severity and readiness to quit
Smokers with
mental illness or
addictive
disorders are
just as ready to
quit smoking as
the general
population of
smokers.
Slide Courtesy J Prochaska; Acton 2001; Prochaska 2004; Prochaska 2006;
Nahvi 2006

14. Barriers to Addressing
Tobacco in Mental Health
• Undervalue of tobacco use as an addiction
• Consumers/ families minimize the health risks of
tobacco
• Professionals/ MH systems have been slow to
change in addressing tobacco
• Lack the knowledge about effectiveness of
treatment
• Lack of advocating for treatment
• Lack of adequate reimbursement
Williams & Ziedonis, Addictive Behaviors, 2004
Clinicians Belief that patients were not interested
in quitting was a major barrier to giving smoking
cessation treatment
Almost HALF (42% of patients) answered “yes” to question
Do you have an interest in quitting on their psychiatric
assessment
from charts (49/117) reviewed same study
77% 83%
0
20
40
60
80
100
120
Himelhoch Williams
Williams et al., in press; Himelhoch et al., 2014

15. Which Approach to Take
Implement current
evidence based
practices?
 Public health model
 Primary care
 Brief strategies
 Limited insurance
coverage
 Telephone
counseling
Develop tailored
approaches?
 Clinical/ co-occurring
treatment model
 Behavioral health
 Face to face
 Longer treatment
 Expanded Medicaid and
Medicare coverage for
treatment

16. Behavioral Health Professionals are
Experts in Psychosocial Treatments
• Counseling = First‐line treatment
• Effective treatments: Individual or group;
CBT, relapse prevention, social skills
• Intensive Treatments
– Sessions > 10 minutes
– More than 4 sessions
– Tobacco treatment specialists
– Behavioral health and/or addictions
specialists

17. Need for Pharmacotherapy in
Tobacco Users w/MI and SUD
No reason not to use
NRT is not a “new drug”
First line treatment/ Recommended all
Comfortable detox for temporary abstinence
Higher levels of nicotine dependence
Psychiatric inpatients not given NRT were >
2X likely to be discharged from the hospital
AMA
Fiore 2008; Prochaska 2004

18. Old NRT Guidelines
With caution (talk to doctor) if:
Recent MI
Smokes < 10 cpd
Pregnant/breastfeeding
Adolescents (Not FDA approved)
Mild side effects
Mostly local
Systemic, less common
NRT Labeling Updates
• No significant safety
concerns associated
with using more than one NRT
• No significant safety concerns
associated with using NRT at the
same time as a cigarette.
• Use longer than 12 weeks is safe
APRIL2013 www.fda.gov/ForConsumers/ConsumerUpdates/ucm345087.htm

19. Varenicline and Suicide
 80,660 smokers prescribed NRT (~63k), varenicline (~11k), and
bupropion (~6k); UK, primary care
 Compared with NRT, the hazard ratio for self harm among
people prescribed varenicline was 1.12 (95% CI 0.67 to 1.88),
and it was 1.17 (0.59 to 2.32) for people prescribed
bupropion.
 No clear evidence that varenicline was
associated with an increased risk of fatal (n=2)
or non‐fatal (n=166) self harm
 No evidence that varenicline was associated
with an increased risk of depression or suicidal
thoughts
Gunnell et al., 2009; BMJ

20. Review of Studies for
Neuropsychiatric Adverse Events
• 17 Pfizer‐sponsored studies (N=8027)
– 1004 with psychiatric
• DOD (N=35,800) VAR vs NRT
– No ↑ in hospitaliza ons for AE
– Prior to FDA warning; gen pop sample
• Depression, aggression/agitation, suicidal
events and nausea
Gibbons et al., AJP, 2013
• VAR not significantly associated with suicidal
thoughts or behavior (OR=0.57)
• VAR not significantly associated with
depression (OR=1.01)
• VAR not significantly associated with
aggression/ agitation (OR=1.27)
• Rates of NPAE 2.28% VAR vs 3.16% for NP

21. Varenicline‐ Major Depression
• 525 past h/o or stable, treated MDE; >10
cpd
• MADRS, HAM, C‐SSRS, SBQ
• 73% on antidepressants (SSRI or SNRI)
• VAR More effective vs placebo
• Week 12 CAR: 35.9% vs 15.6% for placebo
(OR 3.35; p<0.001)
• 24 and 52 week outcomes also significant
Anthenelli et al., Ann Int Med, 2013

22. No Worsening of Depression Scores
No difference in AEs (abnormal dreams, anxiety, agitation,
restlessness, SI)
Anthenelli et al., Ann Int Med, 2013

23. Safety and Efficacy of Varenicline
for Smoking Cessation Schizophrenia/
Schizoaffective Disorder
P=0.09
OR: 6.18
95% CI: 0.75, 50.71
P=0.046
OR: 4.74
95% CI: 1.03, 21.78
Participants(%)
10/83
(11.9%)
2/43
(4.7%)
16/83
(19.0%)
1/43
(2.3%)
Williams et al., J Clin Psychiatry 2012
At Weeks 12 and 24
Abstinentsubjects(%)
Week
24
By week
Varenicline
Placebo
Varenicline
Placebo

24. No Worsening Schizophrenia
PANSS by Week Mean Score
Mean baseline total score
Varenicline: 55.8
Placebo: 54.4
Total score
Week
No significant changes in PANSS from
baseline in any treatment arm in total score
or sub-scores
Positive symptom score Negative symptom score
Anxiety item Depression item
Varenicline Placebo
Williams et al., J Clin Psychiatry 2012

25. Maintenance Varenicline
Greater abstinence at 1 year
87 smokers with
SCZ/ BPD from
open label phase
Randomized at week 12 to 1mg BID
Evins, JAMA 2014; Pachas et al., JDD 2012

26. No treatment effect on psychiatric symptoms, health, BMI
Evins, JAMA 2014; Pachas et al., JDD 2012

27. Improved Mental Health with
Quitting Smoking
• Meta‐analysis 26 studies (14 gen pop, 4 psychiatric, 3
physical conditions, 2 psychiatric or physical, 2 pregnant, 1
post‐op)
Taylor et al, BMJ, 2014

28. Reduced Access to Tobacco
Treatment in Behavioral
Health Settings
• Nicotine dependence documented in 2% of
mental health records
• Only 1.5% of patients seeing an outpt
psychiatrist received treatment for smoking
Peterson 2003; Montoya 2005; Himelhoch 2014
Less than half (44%) of
clinicians in community
mental health sites ask their
patients about smoking

29. State Hospital Smoking Survey
2011; 206 Hospitals Surveyed; 80% response rate
Almost 80% no‐smoking on premises
Less than 35% treatment
Schacht et al., NASMHPD Research Institute, Inc. 2012
0
20
40
60
80
100
2006 2007 2011
% Tobacco
Free State
Hospitals
Treatment
35%

30. Less than Half of US Substance
Abuse Facilities Treat this Substance
National survey of 550 OSAT units (2004–2005)
– 88% response rate
41% offer smoking
cessation counseling
or pharmacotherapy
38% offer individual/group counseling
17% provide quit‐smoking medication
Friedmann et al., JSAT 2008
41%

31. This probably isn't the best
way to quit smoking

32. Conclusions
Reduced lifetime quitting
Higher levels of nicotine dependence and
psychosocial factors
Need for combination (medications +
counseling) approaches
Treatments safe and do not worsen illness
Reduce barriers to treatment in behavioral
health setting