Shifting the Paradigm: Comprehensively Addressing Tobacco Use at Community Behavioral Health Centers Texas Council of Community Centers Annual Conference San Antonio, Texas June 22, 2016 Panel Presenters: Lorraine R Reitzel (University of Houston) Cho Lam (Rice University) Bill Wilson (Austin/Travis County Integral Care) Carol Parker (Spindletop Center) Teresa Williams (Austin/Travis County Integral Care) Bryce Kyburz (Austin/Travis County Integral Care) Tim Stacey (Austin/Travis County Integral Care) Funding provided by: AGENDA Background on tobacco use & disparities Benefits of comprehensive tobacco free programs Overview of Taking Texas Tobacco Free (TTTF) Services and resources offered through TTTF Preliminary results Spindletop Center: A case study TOBACCO USE IN THE U.S. Approximately 25-27% of the U.S. adult population reports current tobacco use Of these, ~80% smoke cigarettes Cigarette smoking prevalence in the U.S. 15.2% of adults (CDC, 2015 – latest release) HAZARDS OF SMOKING Smoking is the single most preventable cause of death and disability in the U.S. (CDC, 2013) Smoking causes more than 480,000 deaths each year About 1 in 5 deaths is related to smoking > 16 million Americans live with smoking-related disease Smoking costs the U.S. ~$289 billion annually in direct medical care and other economic costs (productivity losses) HAZARDS OF SMOKING Smoking causes and/or contributes to: At least 10 types of cancer (lung, esophagus, larynx, mouth, throat, kidney, bladder, pancreas, stomach, cervix) (NCI) 30% of all cancer deaths (CDC) 90% of all lung cancer deaths (ACS) Numerous other medical conditions (e.g., strokes, COPD, reduced fertility, heart disease) MENTAL HEALTH & SMOKING DISPARITIES 36% of adults with mental illness smoke cigarettes Consume 31% of all cigarettes sold in the United States Spend 25% of their income on tobacco Smoke differently Take deeper drags, smoke more per day than average smoker, smoke cigarette to very end and pick up butts CDC. Vital Signs, Feb. 2013 PEOPLE WITH MENTAL ILLNESS… Suffer disproportionately from smoking-related disabilities and deaths People with mental illness make up one-fifth of the U.S. population, yet they account for as many as half of all premature deaths every year that are attributed to smoking 50% of people in substance abuse recovery die from tobacco use (Bandiera et al., 2015) Die, on average, 25 years earlier than those without mental illness Smoking is the leading risk factor associated with mentally ill persons’ shorter lifespan SMOKING AND MENTAL HEALTH Individuals with mental illness: Are often directly targeted for tobacco marketing Are at higher risk for tobacco use because of the mood-altering effects of nicotine Are more likely to be poor and have stressful living conditions Lack access to health insurance, health care, and help to quit PSYCHOLOGICAL DISTRESS & SMOKING SAMHSA. CBHSQ Report; July 2013. Data from the National Health Interview Survey QUITTING Quitting smoking is very difficult Approximately 70% of all smokers want to quit and over 40% attempt to quit each year, but less than 5% are successful It often takes multiple tries to be successful and tobacco addiction is best viewed as a chronic condition Cigarettes and other tobacco products are highly addictive, by manufacturer intent BENEFITS OF QUITTING FOR INDIVIDUALS WITH MENTAL ILLNESS Smoking cessation is associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke. The effect size seems as large for those with psychiatric disorders as those without. The effect sizes are equal or larger than those of antidepressant treatment for mood and anxiety disorders. (Taylor et al., 2014) Smoking cessation is associated with risk reduction for mood/anxiety or alcohol use disorder, even among smokers who have had a pre-existing disorder (Cavazos et al., 2014) Reducing tobacco use among individuals with mental illness can increase efficacy of psychotropic medications …BUT PROVIDER BARRIERS Lack the necessary knowledge about tobacco addiction, the relation between tobacco use and mental illness, and cessation treatments. This leads to: Reduced confidence in their abilities to deliver cessation treatments Limited knowledge about the interactions between nicotine and psychiatric medications Failure to address tobacco use on the treatment plan Mental health employees have high smoking rates (between 30% to 50%) COMPREHENSIVE TOBACCO-FREE CAMPUS PROGRAMS/POLICIES Effects of policy-level interventions may rival those of individual treatments, and exert greater reach. (Anderson et al., 2000) TOBACCO FREE POLICIES: EVIDENCE Meta-analysis: tobacco-free workplace policies reduce tobacco use prevalence among employees and increase cessation (Hopkins et al., 2010) Financial benefits: reduced absenteeism, reduction in smoking- related fires, increases in employee productivity, and averted medical costs No easy smoke breaks Would save $48 to $89 billion dollars per year if implemented across U.S. (Mudarri, 1994) Smokers employed in workplaces with complete smoking bans smoke fewer cigarettes per day, are more likely to consider quitting, and quit at higher rates than those employed at workplaces with partial or no bans (Brownson et al., 2002) TOBACCO FREE POLICIES: EVIDENCE 9x more cost-effective than an individual-level intervention that offered free nicotine replacement therapies (NRTs) to employees in the absence of such a policy (Ong et al., 2005) May help ex-smokers maintain abstinence by eliminating smoking cues and temptations in the workplace Reduce exposure to environmental tobacco smoke among non- smokers (Hopkins et al., Brownson et al.) Changes smoking norms, employees/consumers and those they relate with in the larger community (e.g., their families, friends) CONSISTENT WITH CARE MISSION Tobacco-free policies/programs show concern about the lifelong health of mental health consumers and staff by discouraging use of a deadly product and reducing exposure to second- or third-hand smoke. Taking Texas Tobacco Free (TTTF): Expanding the Integral Care Campus and Community Model into a Statewide Cancer Prevention Program Project period: 12/01/13 – 11/30/16 Local Mental Health Authorities (LHMAs) of Texas TEXAS POLICY INITIATIVES ON TOBACCO AND MENTAL HEALTH DSHS mandated that all Local Mental Health Clinics within Texas be tobacco-free campuses within upcoming 3 years. Failure to comply with mandate will hinder clinic eligibility for state funds Opportunity to capitalize on policy to implement comprehensive evidence-based Tobacco Free Workplace Programs Austin Travis County Integral Care is a forerunner of this initiative Taking Texas Tobacco Free project expands this program across the state Taking Texas Tobacco Free (TTTF) Goals Prevent cancer by helping tobacco-using Texans with mental illness, as well as those associated with their care, become tobacco-free and reduce their exposure to secondhand smoke. Achieve this goal through: Development and implementation of tobacco-free campus policies Integration of tobacco use assessment and tobacco treatment services into clinical practice Offering evidence-based support to assist with quit tobacco attempts Offering tobacco treatment education and training, including specialized training Providing practical guidance and technical consultation TTTF STUDY DESIGN PLANNING & IMPLEMENTATION & -19 LMHAs WRAP UP PREPARATION EVALUATION (MONTHS 30-36) (MONTHS 1-6) (MONTHS 6-30) • READINESS SURVEYS • BEGIN CESSATION • FINAL ANALYSIS PROGRAMS & • SCHEDULE OUTREACH • RESULT TRAININGS PREPARATION & • TRAINING SERVICES DISSEMINATION • SCHEDULE TO EMPLOYEES COMMUNITY • CONTINUED OUTREACH • COHORT 1 AND 2 CONSULTATION ACTIVITIES WITH LMHA’s Needs/Readiness Surveys Administered to clinic leaders at 38 LMHAs; 50 items Constructs: e.g., training needs, smoking rates, basis of interest Response rate = 57.9% (22 of 38 potential centers) Selected Cohort 1 (7 LMHAs) and Cohort 2 (11 LMHAs) + late add on (1 LMHA) Cohort 2 Involved LMHAS Texas Panhandle Region (Amarillo) Community Healthcore (Longview) Cohort 1 Nueces County (Corpus Christi) Heart of Texas Region MHMR Andrews Center (Tyler) (Waco) StarCare (Lubbock) Betty Hardwick Center (Abilene) Coastal Plains (Portland/Rockport) Pecan Valley Centers Helen Farabee Centers (Wichita Falls) (Granbury) Border Regions (Laredo) Metrocare Services (Dallas) Bluebonnet Trails (Round Rock) Emergence Health Network (El Denton MHMR (Denton) Paso) Gulf Bend (Victoria) Spindletop Center (Beaumont) Add on (affectionately known as “cohort 3”) Permian Basin Centers (Midland/Odessa) Central Counties Services (Kileen) KICK-OFF EVENT Texas Council of Community Centers Meeting San Antonio, TX June 2014 Memorandum of Agreement Pre-implementation Surveys Clinic Leader Survey 26 items Confidence Motivation Implementation Pre-implementation Surveys Clinical Provider Survey 24 items Tobacco tx practices Training history Pre-implementation Surveys Employee Survey 25 items Tobacco use/history Smoking norms Quit attempts Training Barriers Individualized Feedback on Pre-tests SETTING A “QUIT DATE” Cohort 2 Already tobacco free Cohort 1 Texas Panhandle Region (Amarillo) 9/01/14 Community Healthcore (Longview) Heart of Texas Region MHMR 7/01/15 (Waco) Gulf Bend (Victoria) 11/20/14 8/01/15 Betty Hardwick Center (Abilene) Nueces County (Corpus Christi) Andrews Center (Tyler) Pecan