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

Transcription

1 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

2 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:

3 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

4 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)

5 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)

6 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)

7 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

8 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

9 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

10 PSYCHOLOGICAL DISTRESS & SMOKING SAMHSA. CBHSQ Report; July Data from the National Health Interview Survey

11 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

12 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

13 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%)

14 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)

15 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 smokingrelated 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)

16 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 nonsmokers (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)

17 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.

18 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

19 Local Mental Health Authorities (LHMAs) of Texas

20 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

21 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

22 TTTF STUDY DESIGN PLANNING & PREPARATION (MONTHS 1-6) READINESS SURVEYS SCHEDULE TRAININGS SCHEDULE COMMUNITY OUTREACH ACTIVITIES -19 LMHAs IMPLEMENTATION & EVALUATION (MONTHS 6-30) BEGIN CESSATION PROGRAMS & OUTREACH TRAINING SERVICES TO EMPLOYEES COHORT 1 AND 2 WRAP UP (MONTHS 30-36) FINAL ANALYSIS RESULT PREPARATION & DISSEMINATION CONTINUED CONSULTATION WITH LMHA s

23 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)

24 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)

25 KICK-OFF EVENT Texas Council of Community Centers Meeting San Antonio, TX June 2014

26 Memorandum of Agreement

27 Pre-implementation Surveys Clinic Leader Survey 26 items Confidence Motivation Implementation

28 Pre-implementation Surveys Clinical Provider Survey 24 items Tobacco tx practices Training history

29 Pre-implementation Surveys Employee Survey 25 items Tobacco use/history Smoking norms Quit attempts Training Barriers

30 Individualized Feedback on Pre-tests

31 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 Add on: Cohort 3 6/01/16 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 Central Counties Services Helen Farabee Centers (Wichita Falls)

32 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

33 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

34 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

35 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

36 SIGNAGE ASSISTANCE Over $1,000 per center to offset cost to create tobacco-free campus signage Provided examples of signage and suggested wording

37 TECHNICAL ASSISTANCE Project management assistance and address challenging situations Access to evidence-based research and practices Contacts for other LMHA staff DROPBOX cloud sharing

38 DROPBOX RESOURCES

39 SOCIAL MEDIA

40 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

41 COMMUNITY OUTREACH

42 PROVIDER AND CONSUMER MESSAGING

43 PROVIDER AND CONSUMER MESSAGING

44 COMMUNITY OUTREACH & TOBACCO-FREE 1 YEAR ANNIVERSARIES

45 COMMUNITY OUTREACH Rittenhouse Health Fair, 9/15/15 People reached = 49

46 COMMUNITY OUTREACH Gulf Coast Arms Wellness Fair, 11/21/15 People reached = 49

47 COMMUNITY OUTREACH Kingdom Builders Community Center, 2/6/16 People reached = 31

48 Texas Tobacco Summit Houston, Texas, 2/22/16 2/23/16 People reached = 15

49 Menninger Health Fair Houston, TX 5/18/16 People reached = 31

50 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!)

51 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.

52 PROGRESS TO DATE: Impact Snapshot 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

53 Total staff trained (1-2 hour trainings) = = 4696 Total # of trainings = 100 general staff trainings & 126 clinical staff trainings

54 STAFF EDUCATION: Cohort 1 General staff: N=671: 46% knowledge increase Clinical staff: N=1298: 41% knowledge increase

55 STAFF EDUCATION: Cohort 2 General staff: N=697: 55% pre to post knowledge increase Clinical staff: N=1431: 63% knowledge increase

56 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.

57 Cohort 1: Clinic Provider Changes Pre-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

58 Cohort 1: Clinic Provider Changes 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

59 Training Outcomes and Clinician Changes 90% Clinician Action Pre/Post TTTF Implementation 80% 70% 60% 50% 40% 30% 20% 10% 0% Asked consumers about smoking Advised consumers to quit smoking Assessed consumers about their desire to quit Assisted consumers with a quit attempt Pre Post

60 Cohort 1: Clinic Provider Changes 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

61 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

62 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

63 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.

64 Training Outcomes and Clinician Changes 80% Training Received Pre/Post TTTF Implementation 70% 60% 50% 40% 30% 20% 10% 0% Received training on assessing for tobacco use Training on pharmacotherapies to treat tobacco dependence Received training on benefits of quitting smoking specific to mental health or substance use disorders Pre Post

65 In the remaining project months, TTTF will continue its mission by working to promote the sustainability of comprehensive tobaccofree programs at the involved institutions and by extending our outreach into the community to assist surrounding agencies to become tobacco-free as well.

66 Case Study QUIT FOR LIFE Spindletop goes Tobacco Free

67 WHO, WHAT, WHERE, WHEN 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

68 What do I do if. 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?

69 COVERAGE AVAILABLE THROUGH CENTER HEALTH CARE PLAN 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.)

70 HELPING OTHERS 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

71 TOBACCO FREE HIRING 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

72 Thank you for allowing us to speak with you today. Contact Taking Texas Tobacco Free staff Bryce Kyburz, TTTF Project Manager Tim Stacey, TTTF Tobacco Cessation Specialist , , See our project website for resources! LIKE us on Facebook: