Shifting the Paradigm: Comprehensively Addressing Tobacco Use at Community Behavioral Health Centers

Texas Council of Community Centers Annual ConferenceSan Antonio, TexasJune 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:

AGENDABackground on tobacco use & disparities Benefits of comprehensive tobacco free

programsOverview of Taking Texas Tobacco Free (TTTF) Services and resources offered through TTTFPreliminary results Spindletop Center: A case study

TOBACCO USE IN THE U.S.

Approximately 25-27% of the U.S. adult population reports current tobacco useOf 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 nicotineAre more likely to be poor and have stressful living

conditionsLack 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

QUITTINGQuitting 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 medicationsFailure to address tobacco use on the treatment planMental 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)

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)

TOBACCO FREE POLICIES: EVIDENCE

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

-19 LMHAs PLANNING & PREPARATION(MONTHS 1-6)

IMPLEMENTATION &EVALUATION

(MONTHS 6-30)

WRAP UP(MONTHS 30-36)

• READINESS SURVEYS

• SCHEDULE TRAININGS

• SCHEDULE COMMUNITY OUTREACH ACTIVITIES

• BEGIN CESSATION PROGRAMS & OUTREACH

• TRAINING SERVICES TO EMPLOYEES

• COHORT 1 AND 2

• FINAL ANALYSIS

• RESULT PREPARATION & DISSEMINATION

• CONTINUED CONSULTATION WITH LMHA’s

TTTF STUDY DESIGN

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)

Involved LMHAS Cohort 1

Heart of Texas Region MHMR (Waco)

Betty Hardwick Center (Abilene)

Pecan Valley Centers (Granbury)

Metrocare Services (Dallas)

Emergence Health Network (El Paso)

Spindletop Center (Beaumont)

Permian Basin Centers (Midland/Odessa)

Cohort 2

Texas Panhandle Region (Amarillo)

Community Healthcore (Longview)

Nueces County (Corpus Christi)

Andrews Center (Tyler)

StarCare (Lubbock)

Coastal Plains (Portland/Rockport)

Helen Farabee Centers (Wichita Falls)

Border Regions (Laredo)

Bluebonnet Trails (Round Rock)

Denton MHMR (Denton)

Gulf Bend (Victoria)

Add on (affectionately known as “cohort 3”) 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 txpractices

Training history

Pre-implementation Surveys

Employee Survey25 items

Tobacco use/history

Smoking norms

Quit attempts

Training

Barriers

Individualized Feedback on Pre-tests

SETTING A “QUIT DATE”Cohort 1

9/01/14

Heart of Texas Region MHMR (Waco)

11/20/14 Betty Hardwick Center (Abilene)

Pecan Valley Centers (Granbury)

1/01/15 Metrocare Services (Dallas)

Emergence Health Network (El Paso)

Spindletop Center (Beaumont)

Permian Basin Centers (Midland/Odessa)

Cohort 2 Already tobacco free

Texas Panhandle Region (Amarillo)

Community Healthcore (Longview)

7/01/15 Gulf Bend (Victoria)

8/01/15 Nueces County (Corpus Christi)

Andrews Center (Tyler)

9/01/15 StarCare (Lubbock)

Coastal Plains (Portland/Rockport)

Border Regions (Laredo)

Bluebonnet Trails (Round Rock)

Denton MHMR (Denton)

10/01/15 Helen Farabee Centers (Wichita Falls)

Add on: “Cohort 3” 6/01/16

Central Counties Services

EDUCATION AND SPECIALIZED TRAINING

Certified Tobacco Treatment Specialist (CTTS) At least one employee per center attends 5-day

training at Rutgers University – center’s tobacco expert

Treating Tobacco Dependence in Mental Health Settings training Two day “Texas” training geared primarily for

prescribers – Jill Williams, MD from Rutgers University

EDUCATION AND SPECIALIZED TRAINING Motivational Interviewing training

One day MI training for clinical staff at centralized locations

Tobacco education and tobacco treatment education for all center staff Provided ON SITE

2 hour training for clinical staff

1 hour training for administrative and non-direct care staff

CLINICAL EDUCATION CRITICAL POINTS Make quitting tobacco part of

an overall approach to wellness

Ask patients if they use tobacco, and advise they quit at every contact

Offer evidence-based treatments to quit smoking

Monitor and adjust mental health medication as needed

Stop practices that encourage tobacco use

Include cessation treatment as part of the mental health treatment offered at each facility

NICOTINE REPLACEMENT THERAPY

Provision of “starter” NRT Distributed for free to consumers and staff

Over $10,000 to each LMHA

NRT was distributed within 6 – 8 weeks at most centers

High demand for NRT and interest in making quit attempt – people are quitting tobacco

SIGNAGE ASSISTANCE Over $1,000 per center to offset cost to create

tobacco-free campus signage

Provided examples of signage and suggested wording

TECHNICAL ASSISTANCEProject management assistance and address challenging

situationsAccess to evidence-based research and practicesContacts for other LMHA staffDROPBOX cloud sharing

DROPBOX RESOURCES

SOCIAL MEDIA

COMMUNITY OUTREACH Success in tobacco free campus policy depends greatly

on the support from the community Individuals trying to quit may avoid secondhand smoke,

making their home and vehicles smoke-free Former smokers may encourage others to quit Tobacco cessation education and outreach programs

may also benefit local communities by reducing their residents’ smoking rates

COMMUNITY OUTREACH

PROVIDER AND CONSUMER MESSAGING

PROVIDER AND CONSUMER MESSAGING

COMMUNITY OUTREACH & TOBACCO-FREE 1 YEAR ANNIVERSARIES

COMMUNITY OUTREACHRittenhouse Health Fair, 9/15/15

People reached = 49

COMMUNITY OUTREACHGulf Coast Arms Wellness Fair, 11/21/15

People reached = 49

COMMUNITY OUTREACHKingdom Builders Community Center, 2/6/16

People reached = 31

Texas Tobacco SummitHouston, Texas, 2/22/16 – 2/23/16

People reached = 15

Menninger Health Fair

People reached = 31

Houston, TX 5/18/16

Other outreach activities

AIDS Services of Austin (May 2016)

Two trainings focused on tobacco use and how it affects individuals living with HIV/AIDS as well as cessation resources.

Distributed TTTF program cessation resources

Health Care for the Homeless – Houston

Perry Street New Hope Housing facility

Texas Comptroller’s Annual Wellness Fair (June 2016)

Presentation of Wellness Program, including the TTTF cessation dissemination materials.

Wellness in Recovery Expo & Symposium (June 2016) in Houston

Hosted resource table and presented “Always a Priority: Reducing Tobacco Use among persons with Mental Health and/or Substance Use Disorders (and service providers!)”

Community Activism Reporting cigarette machines in areas where minors have

access to them to the FDA.

Working with local businesses to make tobacco use warning signs more prominent and tobacco advertisement signs less prominent to patrons and youth.

Over the course of the project, TTTF staff has traveled thousands of miles across Texas to assist over 250 community mental health clinics to implement tobacco-free policies on their campus.

All centers have become tobacco-free Minimal compliance issues

Addressing high tobacco use areas and specialty units (crisis units, residential treatment centers)

Increased assessment for tobacco use and desire to quit Tens of thousands of tobacco use assessments have been delivered to unduplicated

consumers

NRT is being readily used by consumers and staff Both project provided NRT as well as additional NRT purchased by centers

PROGRESS TO DATE: Impact Snapshot

Total staff trained (1-2 hour trainings) =

2272 + 2326 + 98 = 4696

Total # of trainings =

100 general staff trainings& 126 clinical staff trainings

STAFF EDUCATION: Cohort 1

General staff: N=671: 46% knowledge increase

Clinical staff: N=1298: 41% knowledge increase

STAFF EDUCATION: Cohort 2

General staff: N=697: 55% pre to post knowledge increase

Clinical staff: N=1431: 63% knowledge increase

PROGRESS TO DATE: Impact Snapshot Quit tobacco groups have been initiated by many centers

Over 70 clinical providers attended specialized prescriber training

Over 200 providers trained in Motivational Interviewing

41 clinical providers became Tobacco Treatment Specialists

Tobacco Education Implemented as part of new employee training

Thousands of center staff and consumers are now protected from SHS exposure.

Vendors, visitors, and community members are also free from exposure to SHS.

Cohort 1: Clinic Provider ChangesPre-program implementation N= 412;

Post-program implementation N=409

Before implementation, 45% asked patients about their smoking status.

After implementation, 64% asked patients about their smoking status.

Odds ratio = 2.03, p = .003

Before implementation, 32% asked patients about their other tobacco use.

After implementation, 48% asked patients about their other tobacco use.

Odds ratio = 1.87, p = .006

Among providers who said they saw, during the past month, at least 1 consumer who smoked:

Before implementation, 59% said they ADVISED smoking patients to quit.

After implementation, 75% said they ADVISED smoking patients to quit.

odds ratio = 2.10, p = .006

Before implementation, 59% said they ASSESSED smoking patients willingness to quit.

After implementation, 76% said they ASSESSED smoking patients willingness to quit.

odds ratio = 2.21, p = .004

Before implementation, 28% said they ASSISTED smoking patients to quit.

After implementation, 61% said they ASSISTED smoking patients to quit.

odds ratio = 4.16, p = .0002

Before implementation, 25% said they ARRANGED follow up to assess smoking patients’ quit progress.

After implementation, 45% said they ARRANGED follow up to assess smoking patient’s quit progress.

odds ratio = 2.50, p = .002

Cohort 1: Clinic Provider Changes

Training Outcomes and Clinician Changes

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Asked consumers aboutsmoking

Advised consumers to quitsmoking

Assessed consumers abouttheir desire to quit

Assisted consumers with a quitattempt

Clinician Action Pre/Post TTTF Implementation

Pre Post

Among providers who said they saw, during the past month, at least 1 consumer who use other tobacco products:

Before implementation, 59% said they ADVISED tobacco-using patients to quit.

After implementation, 80% said they ADVISED tobacco-using patients to quit.

Odds ratio = 2.67, p = .007

Before implementation, 60% said they ASSESSED tobacco-using patients willingness to quit.

After implementation, 81% said they ASSESSED tobacco-using patients willingness to quit.

Odds ratio = 2.85, p = .005

Before implementation, 40% said they ASSISTED tobacco-using patients to quit.

After implementation, 71% said they ASSISTED tobacco-using patients to quit.

Odds ratio = 3.64, p = .001

Before implementation, 32% said they ARRANGED follow up to assess tobacco-using patients’ quit progress.

After implementation, 53% said they ARRANGED follow up to assess tobacco-using patients’ quit progress.

Odds ratio = 2.54, p = .007

Cohort 1: Clinic Provider Changes

Among providers who said they saw, during the past month, at least 1 consumer who smoked or used other tobacco products:

Before implementation, 15% said they provided behavioral counseling to help patients quit.

After implementation, 17% said they provided behavioral counseling to help patients quit.

Odds ratio =1.15, p = not significant

Before implementation, 11% said they provided NRT to help patients quit.

After implementation, 34% said they provided NRT to help patients quit.

Odds ratio = 4.09, p = .0003

Before implementation, 4% said they provided non-nicotine based medication to help patients quit.

After implementation, 6% said they provided non-nicotine based medication to help patients quit.

Odds ratio =1.43, p = not significant

Before implementation, 28% said they provided any medication to help patients quit.

After implementation, 50% said they provided any medication to help patients quit.

Odds ratio = 0.39, p = .0007

Cohort 1: Clinic Provider Changes

Training received in the last 12 months:

Before implementation, 6% said they received training on assessing consumers for tobacco use.

After implementation, 71% said they received training on assessing consumers for tobacco use.

Odds ratio = 40.88, p < .0001

Before implementation, 6% said they received training on using medications to help consumers quit.

After implementation, 64% said they received training on using medications to help consumers quit.

Odds ratio = 28.96, p < .0001

Before implementation, 8% said they received training on effects of nicotine on psychiatric meds.

After implementation, 64% said they received training on effects of nicotine on psychiatric meds.

Odds ratio = 19.32, p < .0001

Before implementation, 8% said they received training on effects of psychiatric meds on tobacco use.

After implementation, 60% said they received training on effects of psychiatric meds on tobacco use.

Odds ratio = 16.82, p < .0001

Cohort 1: Clinic Provider Changes

Training received in the last 12 months:

Before implementation, 13% said they received training on the use of counseling and behavior therapies to treat tobacco use (e.g., motivational interviewing).

After implementation, 53% said they received training on the use of counseling and behavior therapies to treat tobacco use (e.g., motivational interviewing).

Before implementation, 11% said they received training on the hazards of smoking and benefits of quitting that are specific to individuals with mental health or substance abuse disorders.

After implementation, 70% said they received training on the hazards of smoking and benefits of quitting that are specific to individuals with mental health or substance abuse disorders.

Cohort 1: Clinic Provider Changes

Training Outcomes and Clinician Changes

0%

10%

20%

30%

40%

50%

60%

70%

80%

Received training on assessing fortobacco use

Training on pharmacotherapies to treattobacco dependence

Received training on benefits of quittingsmoking specific to mental health or

substance use disorders

Training Received Pre/Post TTTF Implementation

Pre Post

In the remaining project months, TTTF will continue its mission by working to promote

the sustainability of comprehensive tobacco-free programs at the involved institutions and by extending our outreach into the

community to assist surrounding agencies to become tobacco-free as well.

Case Study

QUIT FOR LIFESpindletop goes Tobacco Free

WHO – it applies to all employees, consumers, family members, contractors, visitors, etc.

WHAT – the policy prohibits the use of all tobacco products including electronic smoking devices

WHERE – on all Center property including vehicles

WHEN - January 1, 2015

WHO, WHAT, WHERE, WHEN

I see someone smoking or using tobacco products on Center property?

A consumer wants me to smoke with him in his home?

I now use tobacco products and want to stop?

Someone asks for an exception to the policy?

Someone asks me about nicotine replacement therapy?

My employee who smokes is taking longer than normal breaks?

What do I do if….

Office Visits – You pay $25 co-pay, the health plan pays the rest

Labs and other related services – You pay 20% after deductible is met

Generic Drugs - $10 co-pay (Zyban has a generic equivalent)

Brand Name drugs (with no generic equivalent) - $30 co-pay or 30% whichever is greater. (Chantrix is a brand name drug with no generic equivalent.)

COVERAGE AVAILABLE THROUGH CENTER HEALTH CARE PLAN

Hand them a Quit for Life Card

Did you stop smoking/using tobacco or know someone who did?

Explain about our Nicotine Replacement Therapy (NRT) program

Help them find a “quit buddy”

Quitting is a process – not everyone succeeds the first time

Ask them if they want to quit – success rate is 50% higher if you do

HELPING OTHERS

Started application survey – June 2015

Decision announced to employees – 9/15

Information on application form – 10/15

Policy implemented – 1/1/16

Policy revisions – 2/16

TOBACCO FREE HIRING

Thank you for allowing us to speak with you today.

Contact Taking Texas Tobacco Free staffBryce Kyburz, TTTF Project Manager Tim Stacey, TTTF Tobacco Cessation Specialist

512-440-4091, bryce.kyburz@atcic.org 512-440-4041, timothy.stacey@atcic.org

See our project website for resources!www.takingtexastobaccofree.com

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