Chad D. Morris

Confronting a Neglected Epidemic: Tobacco Cessation for Persons with Mental Illnesses and Substance Abuse Problems

Tobacco use exerts a huge toll on persons with mental illnesses and substance abuse disorders, accounting for 200,000 of the annual 443,000 annual tobacco-related deaths in the United States. Persons with chronic mental illness die 25 years earlier than the general population does, and smoking is the major contributor to that premature mortality. This population consumes 44% of all cigarettes, reflecting very high prevalence rates plus heavy smoking by users. The pattern reflects a combination of biological, psychosocial, cultural, and tobacco industry-related factors. Although provider and patient perspectives are changing, smoking has been a historically accepted part of behavioral health settings. Additional harm results from the economic burden imposed by purchasing cigarettes and enduring the stigma attached to smoking. Tailored treatment for this population involves standard cessation treatments including counseling, medications, and telephone quitlines. Further progress depends on clinician and patient education, expanded access to treatment, and the resolution of existing knowledge gaps.

What Do Persons with Mental Illnesses Need to Quit Smoking? Mental Health Consumer and Provider Perspectives

OBJECTIVES Forty-one percent (41%) of persons in the U.S. who reported having recent mental illnesses also smoke cigarettes. Tobacco use among this population is associated with up to 25 less years of life and excess medical comorbidity compared to the general population. While research demonstrates that tobacco interventions can be effective for persons with mental illnesses, they are not commonly utilized in clinical practice. The current study explored how to adapt evidence-based tobacco cessation interventions to meet the unique physiological, psychological, and social challenges facing persons with mental illnesses. METHODS Ten focus groups were conducted utilizing a semi-structured discussion; 5 for adult mental health consumers (n = 62) and 5 with mental health clinicians and administrators (n = 22). Content analysis was used to organize themes into categories. RESULTS Five thematic categories were found: (1) Barriers to treatment, (2) Resources and infrastructure, (3) Negative influences on smoking behavior, (4) Knowledge deficits, and (5) Treatment needs. CONCLUSIONS These findings are instructive in developing appropriate tobacco cessation services for this population. Specifically, these data have been incorporated into a mental health provider toolkit for smoking cessation and have informed the development of a tobacco cessation intervention study.

Smoking reduction for persons with mental illnesses: 6-month results from community-based interventions.

Persons with mental illnesses use tobacco at significantly higher and heavier rates than the general population, and suffer greater tobacco- related morbidity and mortality. However, there are few existing tobacco cessation interventions for these individuals. This study examined two tobacco cessation interventions, a telephonic quitline intervention (counseling and nicotine replacement therapy) and a community-based group counseling intervention with adults currently receiving community mental health services. At 6-month follow-up, both groups demonstrated significantly reduced tobacco use, but participants who received both quitline services and the group counseling intervention were significantly more likely to have a 50% tobacco use reduction. Across groups, the overall intent-to-treat cessation rate was 7%. Tobacco dependence, depression symptoms, and psychotic symptoms decreased significantly for all treatment groups, while health and mental health functioning increased. Findings suggest that common community tobacco cessation services are effective for this population.

Smoking cessation behaviors among persons with psychiatric diagnoses: Results from a population-level state survey

BACKGROUND Persons with psychiatric illnesses are disproportionally affected by tobacco use, smoking at rates at least twice that of other adults. Intentions to quit are known to be high in this population, but population-level cessation behaviors and attitudes by mental health (MH) diagnosis are not well known. METHODS A population-level survey was conducted in 2008 to examine state-level tobacco attitudes and behaviors in Colorado. Respondents were eligible for the study if they had non-missing values for smoking status (n=14,118). Weighted descriptive and multivariate analyses were conducted of smoking prevalence, cessation behaviors, and attitudes toward cessation by MH status and specific diagnosis. RESULTS Among respondents with MH diagnoses, smoking was twice as prevalent as among respondents without an MH diagnosis, adjusted for demographic characteristics (adjusted odds ratio 2.2, 95% confidence interval 1.6-3.1). Compared to smokers without an MH diagnosis, those with MH diagnoses were more likely to attempt quitting (58.7% vs. 44.4%, p<0.05), use nicotine replacement therapy more often, and succeed in quitting at similar rates. Smokers with anxiety/PTSD were less likely to quit successfully compared those with other MH diagnoses (0.7% vs. 11.9%, p=0.03). CONCLUSIONS This population-level analysis found that smokers with mental illness are more likely than those without mental illness to attempt quitting and to use cessation treatment at similar rates, but those with anxiety are less likely to achieve short-term abstinence. Additional approaches are needed for smokers with mental illness in order to reach and sustain long-term abstinence from smoking.

Tobacco use in youth with mental illnesses

Despite an abundance of literature documenting the prevalence and dangers of youth tobacco use, there is a relative dearth of literature in the area of effective cessation treatments for youth (Fiore et al. in Clinical tobacco guideline: treating tobacco use and dependence, 2008). Additionally, although it has been widely accepted that mental illness is highly correlated with tobacco use and dependence, little research has been done to support prevention and cessation efforts for youth with mental illnesses. This paper summarizes the literature on tobacco use and cessation in youth, with a focus on describing the existing knowledge base for youth with mental illnesses.

Multiple Perspectives on Tobacco Use Among Youth With Mental Health Disorders and Addictions

Purpose. Youth and young adults with mental health disorders and addictions are at a high risk of becoming nicotine dependent, and at least half will die of tobacco-related diseases. In comparison to the general population, this population also faces neurobiological and psychosocial vulnerabilities. There is a critical need for community services and research targeting tobacco interventions for these individuals. Methods. A concurrent mixed methods study was conducted by collecting data from in-depth key informant interviews, focus groups, and a survey. Qualitative key informant interviews with healthcare professionals (n = 11) and youth focus groups (n = 32) were conducted by using semi-structured questioning regarding barriers and facilitators to tobacco interventions. Content analysis was used to code transcripts and categorize themes. Survey data were also collected from 230 smokers ages 13 to 17 years (n = 62) and young adults ages 18 to 25 years (n = 40) at three community mental health centers. The survey inquired about tobacco use, motivation to quit, history of quit attempts, and treatment preferences. Results. Five thematic categories were identified in both the adult key informant interviews and the focus groups with youth: (1) motivation to quit, (2) cessation treatment needs, (3) social influence, (4) barriers to treatment, and (5) tobacco-free policy. Among those surveyed, 44% currently smoked. Youth and young adult survey respondents who smoked were often motivated to quit, few had used proven tobacco cessation aids, but there was interest in access to nicotine replacement therapy. Conclusion. Merged qualitative and quantitative findings support past literature regarding youth in the general population but also expand upon our knowledge of issues specific to youth and young adults with mental health disorders and addictions. Findings suggest interventions warranting further attention in community treatment settings. (Am J Health Promot 2011;25[5 Supplement]:S31-S37.)

An expanded opportunity to provide tobacco cessation services in primary care

The Patient Protection and Affordable Care Act, and Centers for Medicare and Medicaid Services (CMS) decision on tobacco cessation counseling support the need for expanded cessation coverage. Primary care practices receiving CMS payments will soon be mandated to offer these services. This commentary discusses the salience of tobacco cessation policy in terms of opportunities for primary care, and anticipated issues in meeting healthcare reform requirements. Comments build upon recent federal policy and suggest areas to which primary care practices will need to attend when operationalizing tobacco cessation policies. Research supports efficacious tobacco cessation interventions delivered in a primary care context. To effectively implement tobacco cessation in primary care, practices will need to address coding and payment issues, define service offerings, identify reporting requirements, align with the medical home model, and increase provider buy-in.