Hello and welcome. I'm Dr. John Torres, SMI technology expert for SMI Advisor and Director of the Digital Psychiatry Division at Beth Israel Deaconess Medical Center. I'm pleased that you're joining us for today's SMI Advisor webinar titled Smoking Cessation for Persons with Serious Mental Illness. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now, it's my great pleasure to introduce our faculty for today's webinar, Dr. Steve Schroeder. Steve Schroeder, MD, is a distinguished professor of health and healthcare at the University of California, San Francisco, UCSF, where he directs the Smoking Cessation Leadership Center, SLCCEL. In 1990 and 2002, he was president of the Robert Wood Johnson Foundation, where he initiated programs in tobacco control that resulted in $500 million in grant expenditures throughout his tenure. The Smoking Cessation Leadership Center worked with professional societies, federal and state organizations, and advocacy groups to both increase the number of smokers who attempt to quit and increase the probability of a successful quit. From 2014 to 2018, he served as a public member of the congressionally mandated Federal Interagency Committee on Smoking and Health. Dr. Schroeder, thank you so much for leading today's webinar and sharing your expertise with us. Thank you very much, Dr. Torres. It's good to be with you all. And I want to say at the outset how glad I am that you're interested in this topic and that I would feel very honored if you would use any or all of my slides in your own presentations, those of you in the audience, and do it with or without attribution. So here are the learning objectives, which I won't read to you. I'll let you read them for a moment. But the goal here is to make you more comfortable and better able to help your clients stop smoking. This is my conflict of interest slide. Some of you may recognize this is in Jordan. And there I am with Joe Camel. But I have no money from either the pharmaceutical or obviously the tobacco industry. So this is a cover of JAMA that honored the 50th anniversary of the report of the Surgeon General. And you can just see how far we've come, but you're going to hear from me how far we have to go. So in spite of all we hear about everything else, COVID and vaping and, you know, all the other problems in our world and in our country, smoking is still a huge deal. There are over 500,000 deaths in the United States each year, over 7 million deaths worldwide. And that's going to increase if current trends stay as they are. 41,000 of those over 500,000 deaths are due to secondhand exposure to people who don't smoke. And more than 16 million people in the United States are walking around with smoking-related illness, most of them with chronic obstructive pulmonary disease. We've had a lot of progress in lowering smoking rates, but there are still 34 million smokers in the United States. Three quarters of them smoke every day, and about one quarter don't. And they average about 14 cigarettes per day. So this just puts in perspective the fact that of the 540,000 or so annual causes of smoking deaths, 240,000 of those occur in people with mental illness and or substance abuse problems. On the right-hand bar, you see the cumulative impact in terms of deaths of all other behaviorally linked issues, and smoking clearly still dominates despite recent progress. Now, here's the good news. There's been a steady increase or steady decrease in the smoking prevalence rates of both men and women. You'll notice the huge gap in the 50s and 60s. And then there was a successful marketing campaign to normalize smoking in women. And that gap is much narrower, but it's still there. And we're down to about a little less than 14% of adults currently smoke. Now, it was thought, well, here's a population basis showing that adult per capita cigarette consumption has hit the peak around 1960. The Surgeon General's report came out in 1964. And I'm told that reporters in the room when it was announced threw away their packs of cigarettes because the data were so clear. You can see the per capita consumption is going down. And we think it's going to continue to go down. With your help, you'll drive it further. Now, it used to be thought that as people quit, it would be the low-hanging fruit, that it's light smokers who would quit, but heavy smokers would keep smoking. And as a result, for the residual number of smokers, the average number of cigarettes per day would go up because you're subtracting the more moderate smokers. So you see in the blue line there, the proportion of people who smoked going from almost 45% in 1965 close to the current 14% today. But you notice with the red line, the number of cigarettes per day held at about a pack a day until 1997. And now it's come down to 14 or less cigarettes per day. And that's good news because if you smoke less, it's easier to quit. So what's in tobacco smoke? The answer is a lot. So there's an estimated 7,000 compounds, including 69 proven human carcinogens. The gases that are listed there, particles. It's important to note that it's not the nicotine that causes the ill health effects of tobacco. It's the nicotine that addicts the smoker, but it doesn't make them sick. This is a slide that I update periodically, and that's the red. The red are more recent data from the literature showing, for example, that people with prostate cancer survive less if they smoke, that you're more likely to get type 2 diabetes. And of great importance for psychiatrists, it looks like there's a vascular component to Alzheimer's. And if you smoke, you're at higher risk of getting Alzheimer's disease. But I'll just let you digest this list. It's staggering. Nothing else that I know in medicine can cause as many illnesses as smoking does. So it's a really noxious thing to do. And then for those who don't smoke, but get exposed to someone else's smoke, you can see the developmental, respiratory, carcinogenic, and cardiovascular issues, including recently childhood depression in the mothers who smoke and teeth grinding, bruxism in children. So these are five cartoons, which I'll summarize for you briefly. The skull and crossbones show that people with mental illness or substance use disorders die up to 10 years earlier than those without those conditions. And most of those deaths are caused by smoking cigarettes. The hard cartoon shows that the most common causes of death among people with mental illness are heart disease, cancer, and lung disease, all of which, of course, are caused by smoking. The middle one, the EKG, shows that drug users who smoke cigarettes are four times more likely to die prematurely than those who do not smoke. The brain shows that mood altering effects are a result of nicotine. And sometimes they can mask the negative symptoms of mental illness. And finally, and I'm going to come back to this, the medicine bottle shows that tobacco smoke can interact with and inhibit the effectiveness of certain medications because they activate enzymes in the liver that deconjugate those medications. So it's interesting. I got married a long time back. Excuse me. We got a lot of fancy wedding gifts, including some nice ashtrays. We haven't had a person who smokes in our house for probably 30 years. So over the last decade or two or three, smoking has been relegated to people who are in vulnerable populations. You see the race, ethnicity, education. Clearly, only 1% of physicians smoke. People who are poor are more likely to smoke. People who are uninsured, who are disabled, LGBT, and serious mental illness. So these are all risk factors for smoking. And this shows a map of smoking prevalence, the bluer, the worse, and showing that there's a concentrated bill in the southeast and a little bit in the middle, which is where a lot of other bad things happen, diabetes, hypertension. I'm proud to say that my state of California and Utah are the two lowest smoking states. And if you correct for Mormons, which Utah is a lot more than California, and they're not supposed to smoke, I would claim California is number one, but we'll even settle for being number two. And this is just a chart. Check this out. And these are lung cancer deaths. I don't have a more recent map, but it's the same currently. You can see how lung cancer deaths are concentrated in those states that have the highest smoking rates. So some people think, well, I've been smoking a long time. The horse is out of the barn. It won't help me. But in fact, it will help you to quit. And these are some of the health benefits. Within two to three weeks, your circulation gets better. Lung function increases. One of the things you might not know is that when you first quit smoking, you're actually liable to cough more because your cilia come back and they clean out the mucous glands that have been so uploaded in smoking. And so some people say, well, I'm coughing more, but that's just pulmonary hygiene. Within a year, your excess risk of coronary heart disease decreases to half that of a continuing smoker. And within 15 years, it's similar to that of people who've never smoked. Within five years, your risk of stroke is reduced to that of people who've never smoked. And lung cancer rates drop, but they never go away. So once you've smoked, you've increased your risk of lung cancer. I'm going to show another slide that demonstrates that. Never too late to quit. These are the years of life you save if you stop quitting. Clearly, the earlier you quit, the better. But even after age 65, it's a good thing to do. And this is a fascinating chart. It's survival curves from people who at the bottom line are never smokers. The next to the top line is people who smoked until age 60 and then quit. And the very top line is those who keep smoking after age 60. So you can see the message is it's never too late. The other message is, boy, does smoking ever cause lung cancer? So you're here because you're interested in behavioral health. And let me expand a little bit on that. About, as I mentioned, 240,000 deaths from smoking occur among people with serious mental illness and or substance use disorders. This population, which is about 22% of the United States, consumes 40%, 40% of all cigarettes sold in our country. Why is that? Population is more likely to smoke. They're likely to smoke more cigarettes if they're to buy more packs. The other thing they do is they're more likely to smoke down to the butt. So if you go outside an AA meeting, you'll just see Marlboro filters. As I mentioned earlier, people with serious mental illness die earlier than others. And smoking is a large contributor to that early death rate. They're also at greater risk for withdrawal from the basic nicotine in the cigarette. And one of the things we want to do as we treat people with mental illness is reintroduce them into normal society, make sure that they feel as well as they can. Hard to integrate, hard to go for a job interview if your fingernails are yellow, if your clothes smell like smoke. So social isolation from smoking actually compounds the social stigma from mental illness. And this is both a good news, bad news slide. The blue line at the top shows current smoking, this is a SAMHSA slide, among adults with past year behavioral health conditions. That's either mental illness or drug abuse disorder or both. And you can see that in 2008, there were 41.5% as compared to 20% of people without those conditions. Now, the bad news is that gap is still there. The good news is that the behavioral health prevalence dropped from 41% to 30%. That's 11.5%. At the same time that the red line only dropped by 5%. So for those of you who are sort of pessimistic that these folks don't want to quit smoking, this graph is testimony to the fact that in fact, smoking cessation does happen. So these are smoking rates among various mental illness populations. And these rates vary depending on what the survey shows. These are SAMHSA data. SAMHSA is really good on this now. But you can see that the rates are so much higher. Remember, the overall population rate, which includes people with behavioral health, is down to less than 14% now. So you can see that incarcerated people have very high rates. What's not on here, people with problem with heroin can be as high as 80%. But again, it's the less fortunate in our society who are more likely to smoke. And unfortunately, also to be ignored or given second class status by politicians and those who are in power of allocating funds, because they don't have a powerful constituency. They tend not to vote. They tend not to give to political campaigns. Now, the tobacco industry knows these data and have targeted different groups. And these are just three examples. On the left, we think is targeted to people with bipolar conditions. The one in the middle, to people with a schizophrenic issue. And the one on the right is menthol and it's targeted to people of color. So let's look at smoking prevalence and substance abuse. This first bullet is astonishing. Half to 90% of people in addiction treatment settings smoke cigarettes. And we know from people who work with this population that smoking is what kills more people than their underlying alcohol or drug use problem. And many people I've talked to say, I'm really so discouraged that I help people quit their alcohol or their heroin or their cocaine, and then they die of lung cancer from the underlying smoking. Now, again, there's been great progress. It used to be, and some of you who trained in mental health and psychiatric hospitals may recall a time when physicians and nurses and patients all smoked together. And that was given as a reward for good behavior. Now, close to 100% of psychiatric hospitals are smoke-free indoors and many are smoke-free outdoors. And there are a lot of myths about smoking and behavioral health. One is that smoking is necessary to self-medicate. And it's interesting as some of the research and papers that sponsored that were actually supported by the tobacco industry. People with mental illness are not interested in quitting. In fact, surveys show the same percentage wish to quit as a general population, about 17%. They're not able to quit. Well, the quit rates are about the same or maybe slightly lower than the general population. So they are able to, and I showed you on that earlier slide that that happens. Quitting worsens recovery from their mental illness. That's not shown. So I'm going to show you a meta-analytic paper from the British Medical Journal shortly that gives you some substance for that. And it's a low priority problem. And I understand this attitude. If someone comes in with withdrawal or has had a criminal record, it may be that you need to attend to the bipolar issue or the suicide issue or the gross psychotic issue. But over time, in the lifetime of the patient, smoking is a very high priority issue. So what does SAMHSA recommend? Tobacco-free facility grounds and policies and integrate smoking cessation into all behavioral healthcare. So we're going to come back as to how to do that now. So this is a meta-analytic study that I showed you by Gemma Taylor and colleagues in the British Medical Journal. This was a Cochrane collaborative meta-analytic study of 26 papers, well controlled. You have to have a good paper to get included in these collaboratives. And they showed important findings. One is smoking cessation leads to less depression, less anxiety, less stress, better mood and quality of life. So it doesn't make things worse, it makes things better. And this is astonishing in the third bullet. The effect sizes of smoking cessation were greater to or equal that of antidepressant drugs for mood or anxiety disorders. Among smokers with pre-existing alcohol use problems, smoking cessation leads to a less likelihood of recurrence or continuation of their alcohol use. So they're more likely to stay sober. And in terms of addictions treatment, smoking cessation is associated with a 25% increased likelihood of long-term absence from alcohol and illicit drugs. So smoking cessation is a twofer. It helps to prevent the problems from smoking and it helps to address the underlying behavioral health condition. So this is a cartoon that explains why it's so hard to quit smoking. When you smoke, nicotine gets into your bloodstream very quickly and goes to two receptors in the middle of the brain, in the nucleus accumbens and the ventral tegmental area, which have dopamine release from nicotine receptors. And that dopamine goes to the prefrontal cortex and it signals pleasure. The same thing happens with alcohol use, with cocaine, with heroin, with sex. And I have a very bizarre brain because when I hear Beethoven, I get a release of dopamine and I feel really great. And this shows what smokers do. They basically titrate their smoking to keep their blood nicotine levels within that band that you see there. And that is why it's so hard to smoke. And that's why the first thing a hardcore smoker wants to do in the morning when they wake up is have that first cigarette to restore the blood nicotine level to the pleasure levels that they're comfortable with. Those of you who've been around someone who's tried to quit smoking know that they can be very unpleasant. They're irritable, they're frustrated, they're angry, they're anxious. It's hard for them to concentrate. They're restless and these other things. And they also gain weight. So it's hard to stop smoking. Fortunately, most symptoms manifest within the first one to two days, peak within the first week, subside within the first two to four weeks. So if you can provide them with nicotine substitutes during this withdrawal, then they can tolerate being off the cigarette much better than if they just do cold turkey, which is why the rate of quitting cold turkey is only about 4%. So I hope you've been motivated now to help people quit smoking. How do you do that? Well, I'm sad to say that most physicians undertreat smokers. And that's true of other clinicians as well. So a survey of the American Association of Medical Colleges of 3,000 physicians representing family medicine, general medicine, OBGYN and psychiatry showed that only 1% are current smokers. That's great. They asked about smoking, they advised to quit, and then they sort of dropped the ball. They didn't recommend any nicotine replacement therapy or follow-up or send to telephone quit lines. So this is where there's room for improvement. And this is a different study by the American Legacy Foundation that showed similar survey results that smokers, when they visit their physicians, a fifth never talk about smoking, only a fifth who talk about it get educational assistance, only 44% get any kind of smoking cessation drug, and over half feel guilty when talking about smoking. So your job is to not make them feel guilty, make them feel glad that they're talking to you about it. So here's a slide I put together, reasons for not helping smokers quit. I'm too busy, I don't know how to do it, I don't get paid any extra, and that's sad to me, you don't pay extra for taking someone's weight or measuring their blood pressure. There are billing codes for smoking cessation, but this should be the right thing that you should do. I don't have available treatments or coverage. The myth that I mentioned earlier that most smokers can or won't quit is stigma, the sort of the unspoken thought, you made a bad choice, therefore I'm not sure I can help you. The respect for privacy, which is understandable, this is your own personal kind of decision. The negative message that I might scare away patients, and here it's reassuring to know that surveys of smokers who have no intention of quitting show that they think less of a physician who won't ask about smoking because they know that smoking is bad for them, even if they themselves are not ready to quit. I, as a physician or a nurse or a social worker, quit and smoked myself, not a good excuse, and then problems with an electronic medical record. So those are all the reasons. Here's a formula that I constructed. I'm not a math whiz, but pretty simple. The number of smokers in the country is a function of the number of new smokers plus current smokers minus quitters. And there's two ways you can quit. You can die or you can be persuaded to stop smoking. And the number of quitters is a function of the number of quit attempts plus the percentage of people who try to quit who are able to quit. And what we really wanna do is drive up quit attempts because then they yield quitters. So there are a number of policies that drive up quit attempts. Raising the price of cigarettes, and it won't surprise you to know that in those states with all the lung cancer cases, they tend to have lower prices, lower taxes, the state taxes on tobacco. Clean indoor air laws, same state variabilities. Countermarketing, such as the truth campaign or the CDC's tips for former smokers or that many states have. The advice of clinician both drives up the number of quit attempts and increases the rate of quitting. If you as a clinician do nothing more, particularly if you're a physician, but nurses too, you do nothing more than advise your patients to quit, you'll double their chances of quitting. And then I'm gonna get into later medications and counseling. So the tools to help you stop smoking include the five A's, which I'm gonna come back to. A shortcut for those who don't feel they're able or want to do the five A's, which is ask, advise, and refer either to a smoking cessation clinic in your setting like a Kaiser Permanente or the telephone quit lines. Medications such as nicotine replacement therapy and others, counseling, and peer-to-peer. And I'm gonna expand on each of these now. So here's the five A's. I'll let you read them, but I want to caution that as I showed on the previous slide, clinicians are really good at the first two, ask and advise, and then they fall off on the last three. I'll let you look at the slide for a minute longer. So what you say, sense the tone. You don't want to say, you don't smoke, do you? You can say it more neutrally. Have you ever smoked cigarettes or used other tobacco products? You don't say, are you a smoker or are you still a smoker? That's a judgmental tone. This is a much more sympathetic tone. The first few weeks after quitting can be hard. Have you felt the urge to smoke? You know that stuff will kill you and if you quit smoking, your cough will get better. This is on the eh-eh side and this is on the yes. Quitting tobacco is one of the most important things you can do for your health. I understand quitting can be hard. I'm here to support you. I'm here to give you resources that can help. I'd like to hear your thoughts about stopping smoking. So these are sort of ways to get the messages across. And tobacco cessation interventions are underutilized. This is a study. This is how adults tried to quit smoking. Many received advice. Most didn't use treatment. Far more used medication and counseling. 80% used both counseling and medication, which is the gold standard of ways to help stop smoking. So I can't emphasize this slide often enough. There's a recent study in 2020 that showed that 80% of physicians felt that nicotine contributed to cancer, heart disease, and lung disease. That's just not true. As a famous British physician said, people smoke for the nicotine and they die from the tar. And it's those 700,000 ingredients in tobacco smoke that cause you to get sick, not the nicotine. But the nicotine is dangerous because it gets you hooked. So nicotine replacement therapy is helpful, not harmful. So here's the basis. Clinicians should encourage all patients attempting to quit to use effective, I misspoke, it's 7,000 ingredients in tobacco smoke, one of which is the basic nicotine. Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except for contraindicated. The contraindications are women who are pregnant, people who use smokeless tobacco, light smokers, and adolescents. The break-off in light smokers is probably five to 10 cigarettes per day. Medications and counseling are the twin pillars to help people quit. So I'm gonna go through the different medications now, starting with the nicotine gum. The advantages are that it might satisfy oral cravings, it might delay the weight gain, and people who stop smoking often gain eight to 12 pounds because smoking curves your appetite. And women in particular are worried about this, telling us it's worth it, and ultimately most of them will get their weight down again. The gum, people can titrate therapy to manage withdrawal symptoms, and you can get a variety of flavors. The disadvantage is that you need to keep coming back to the gum, that it can impair significant dental work. You have to chew it correctly, and I'm gonna show how to do that on the next slide. And gum chewing might not be socially acceptable. I should mention that those of you who saw the second inauguration of President Obama, interesting that we mentioned that now at this time, notice that he was chewing gum, he was chewing NRT, and his recent biography shows that he was still smoking eight to nine cigarettes per day during his second term because the job was so stressful. So here's how you chew. You put it in your mouth and chew slowly. You stop chewing at the first peppery taste or tingling sensation. You park the chiclet between your cheek and your gum, and then chew again when the peppery taste or tingle fades. And when you don't get that anymore, you spit it out and get a new version. If you chew it too hard and vigorously, you'll get an overdose of the nicotine. And don't eat or drink 15 minutes before or after use because it lowers the rate of the nicotine getting into the brain. The lozenge has been increasing in popularity. The same advantages of the gum, the delaying of their own craving, the satisfying of their own cravings, the delaying of the weight. Lozenges are easier to use and conceal, so it might be more socially acceptable. And like the gum, you can titrate. The disadvantages are, like the gum, the frequent dosing, and some people get GI side effects, as I mentioned here. The patch is sort of the basic nicotine replacement therapy. You slap it on in the morning, and it gives you a steady drip, drip, drip of the nicotine. It doesn't give you the pulse that the gum or the lozenge gives you, but it takes the edge off. The disadvantages are the allergic reactions to nicotine. So people with a severe neurologic condition shouldn't use it. But it's a mainstay. It comes in three doses. It's easy to use. And once you slap it on, you don't have to worry about, is the patient going to comply? Boreticline, which is manufactured by Pfizer, known as Chantix, is probably the most effective of the drugs. I'm gonna show you that in a minute. It's a designer drug that binds to the nicotine receptors in the brain, in that cartoon I showed you earlier. And it stimulates low-level agonist activity. So it gives you a little bit of release of the dopamine. But then when you smoke, it blunts the kick that you get from the nicotine. So you're less likely to get withdrawal, and you're less likely to get a reward from the smoking. So that's good news. The common side effects, which occur around 5% or more than 5%, and the reason that you start the drug at half dose for a couple of weeks before going to full dose, are nausea, sleep disturbances, constipation, flatulence, and vomiting. Now, when Boreticline first came on the market, there were several case reports from psychiatrists showing people with suicidal ideation and even some suicide cases. It was unclear whether this was because of the drug itself, whether because people were reacting to stopping smoking, or because the same people who smoke may be prone to those conditions. Interesting, when nicotine replacement therapy came on the market several decades ago, the same reports were given, that people were maybe thinking of committing suicide from the NRT. The FDA made Boreticline have a black box warning and asked Pfizer to do a trial. So they did this very large EGLE trial, a large randomized controlled trial with over a thousand psychiatric patients. They got the drug. There was no increase in psychiatric symptoms, much greater smoking cessation. The FDA said, okay, thank you. We'll remove the black box. The other bonus is it showed that if you use a Boreticline drug to stop smoking, you may have less of a craving for drinking if you're a problem drinker. The last drug I'll mention is bupropion, which is an antidepressant. And people using it for antidepressant noticed that their patients who were smoking seemed to have less craving to smoke and were willing to quit. So bupropion seems to act on the brain in terms of dopamine and norepinephrine. And it reduces life for Boreticline, reduces craving and symptoms of nicotine withdrawal. The disadvantages and advantages are it's easier to use. It can be used in nicotine replacement therapy. It might delay the weight gain. And if you have a patient who's depressed, it's a twofer. It shouldn't be used in people with a seizure disorder because it might increase the, it might lower the threshold for seizures. And that's the major disadvantage of those severe cirrhosis and taking MAO inhibitors may be a problem too. So combination therapy is a hallmark of chemotherapy for smoking cessation. It usually consists of combination NRT, which is a patch plus either the gum. And I didn't go into detail on the inhaler or the nasal spray, which are other ways to give nicotine, but are not used very often. Another combination therapy is bupropion, sustained release and nicotine replacement therapy. There have been some reports of using Boreticline with nicotine replacement therapy. We're not sure how well that works, but there have been a couple of reports that shows that smoking cessation rates are actually increased if you do that. And here's one of the studies showing that. So they did a 24 point abstinence with the patch plus, and this is amazing. The Boreticline plus the NRT patch gave us 65% smoking cessation rate in 24 weeks and Boreticline by itself, 46%. The different trials showed it was over 50%. So I'm gonna show you, this is higher than most studies. So an important thing that psychiatrists ought to know is that the ingredients, the 7,000 ingredients in tobacco smoke act on enzymes in the liver to accelerate the deconjugation of a lot of drugs. And you see them here, many of which are psychoactive. I've highlighted caffeine in red because smoking deconjugates caffeine. If you notice when your patients stop smoking, they're more liable to say, and they're heavy drinkers of coffee, which a lot of them are, they're liable to say, I'm getting more and more jittery. So you might wanna have them scale back on their coffee or switch to half decaf, half regular caffeine if they stop smoking. Many patients who take psychiatric illnesses, medications, don't like those drugs. And if you get them to stop smoking, they'll be able to reduce their level of those drugs and reduce the level of side effects. So it's a very important bonus here. And this is another cartoon or slide showing all the different drugs whose medication levels are increased if you stop smoking, decreased if you smoke. So you better take extra strong dosage of them. So I'm gonna show you some slides about the smoking cessation literature, but I wanna give you some caveats first. You should think of smoking as a chronic condition like heroin abuse, diabetes, hypertension, but drug treatment is often short, 12 weeks, in contrast to say maintenance of basic methadone. You see one smoker, you see one smoker. There's a great continuum of severity and addiction and your treatment should be tailored. And the more someone smokes and the earlier they start to smoke, the more heavily they should be medicated. Volunteers for studies are likely to be more motivated to quit. They've got to come in and get bloods drawn and urines taken. So they're more likely to have higher quit rates. The placebo and the drug groups in trials tend to have state-of-the-art counseling better than found in real practice. Counseling is not a monolithic black box. And most drug trials sadly have excluded patients with mental illness. Although Sharon Hall at my institution, UCSF, showed that she got with really intensive therapy as many as half of her patients with mental illness to stop smoking with state-of-the-art treatment. So here's a very important slide. I wanna make several points about it. One is, you'll notice that the placebo rate of quitting in all these different trials, which are aggregated by the Cochrane Collaborative, range from eight and a half to 12%. This is much higher than in the real world, where the real world quitting cold turkey rate is about 4%. The reason these are higher is they've gotten really good counseling as part of the placebo arm. The other thing I would say is it's clear that drugs plus medication clearly give you a better shot at quitting than counseling by itself. So the yellow bars are drugs and counseling. The final thing I'll say is it's hard to compare. I'm not sure we think that the spray is better than the lozenge. There's just so few trials, but there is increasing evidence that Vereniclein, either by itself or with NRT, probably gives the highest quit rates. The final thing I'll say is notice that even though all these trials improve the rate of quitting, the bulk of the smokers remitted and relapsed and went back to smoking. And it takes the average smoker 10 to 30 attempts before they're able to quit. So the message ought to be great. You tried to quit, even though you didn't quit this time. Let's try it a second and a third and a fourth time, et cetera. So why help mental health consumers quit? Better health, as I've showed you. You live longer as I showed you. Better effective medications. Less social isolations. Saving money. I'm going to get back to that in a minute. And you'll be better with your underlying illness. So again, really great reasons. Here's the bunny slide. People with mental illnesses or addictions may spend up to a third of their income. That's astonishing on smoking. And this is a little, these are data from 2020. So the tobacco taxes are probably accurate. The average smoker, and it varies from state to state. In high states with high tobacco taxes, it's more. In Alabama, it's going to be less. They're spending over $2,000 per year. And these are people who often have constrained incomes. What about quitting and mental illness and quit lines? Well, every person in this country has free access to a toll-free quit line. A lot of people wondered, do these work? So you can call free, get counseling, state-of-the-art counseling from a trained counselor. And you call at 1-800-QUIT-NOW. The question for a long time was, do they work with people with serious mental illness? So what are the quit lines? We provide counseling at no extra cost, trained by state and specialists. They give up to four to six personalized sessions. And the quit line contract varies by state. So you should try to find out what your state covers. Some of them give vouchers for nicotine replacement therapy at no cost or lower cost. And people who call the quit lines who are motivated, and I'll grant that, have up to a 30% quit rate for patients who complete the sessions. And sadly, most clinicians and most patients don't know about quit lines and only about 1% to 2% of smokers nationally ever use them. So one of the things that when we've been working with quit lines, they said, well, I'm not sure we want to work with patients with mental illness because I'm not sure how well we're going to do. And then we actually did prevalence and found that when you screen, you have a lot of patients with illness and almost half, 42.8% of unique tobacco users who receive evidence-based treatment also had an underlying behavioral health condition, either mental illness or substance use disorder or both. And they benefit. So some people in mental health say, well, do we treat our patients different from smokers who don't have that underlying problem? And the answer is no, generally not. They benefit from the same medications I showed you, the same combination of counseling and pharmacotherapy. You may need to treat the drug and the counseling for a longer period of time. And again, view the failed quit attempt as a practice, not as a failure. So peers can be really helpful in helping smokers with mental illness to quit. Peer-led support groups, community referrals have been shown to be helpful and peers can be trained to integrate tobacco cessation and wellness services into existing roles and responsibilities in community settings and peer settings. And a lot of treatment settings include peer specialists who are former smokers or even current smokers on their staff, either as paid or as volunteers. So what about e-cigarettes? You've heard a lot about them and I'm not going to spend a lot of time on them. You may have some questions on them for me later. The 2020 Surgeon General's report is as follows. The evidence for smoking cessation from e-cigarettes is in general not adequate, but it's suggestive that use of e-cigarettes with nicotine is associated with greater smoking cessation compared with e-cigarettes that don't contain nicotine. The evidence is suggestive, but not sufficient to infer that more frequent use of e-cigarettes is associated with increased smoking cessation compared to less frequent use of e-cigarettes. And I'll caution you that this is a work in progress. We're still trying to find out how it works. This is a very important article in the New England Journal of Medicine from the United Kingdom where harm reduction is probably more of a practice than it is in the United States. The slide got a little bit messed up in the translation, but let me walk you through it. With e-cigarettes, a fifth, 21.2% of patients who use them were abstinent in 52 weeks, as opposed to 12% of people who only use nicotine replacement smoking. The second line shows that in those who were still smoking, but lowered the amount of smoking, 12.8% lowered the amount of smoking with e-cigarette, as opposed to 7.4% with NRT only. And these were significantly different settings. The final slide, it got a little bit wrecked in translation, but I'll read it for you. And what people are worried about e-cigarettes said is that for those who quit after using e-cigarette, any percent were still using the e-cigarette. For those who quit using nicotine replacement therapy, only 9% were. The interesting thing about this issue of the New England Journal was it was accompanied by two editorials cautioning about e-cigarette use, showing that in the United States, e-cigarettes are still very controversial, particularly their use among youth. So let's turn to the final thing that's been happening, which is COVID. I think you know all these things, but let me just sort of do a capsule summary. COVID hits vulnerable populations just like smoking does. Job loss, financial stress, food insecurity, housing insecurity, living in cramped quarters, psychological distress. And we don't know the data yet, but there are two theories on smoking and COVID. One is because COVID is so stressful, people who used to smoke or are currently smoking will either start smoking again or smoke more. The counter narrative is because they're in such closed quarters, they're so worried about infecting, about exposing others to secondhand smoke, they might smoke less. We don't know which of those two pertains. My guess is in the real world, we'll see both things happening. And finally, if there's financial stress, smoking obviously is another economic drain. So what about COVID and smoking? We need to understand that much more. There's not good evidence, although there's one study that has been criticized that shows that smoking increases chances of getting infected. And there's some speculation that nicotine, in fact, may protect from infection because it attaches on to the ACE receptors in the lung, which are the very same receptors as the COVID virus gets on. So we need to learn more about this. But as expected, when people are hospitalized with COVID-19 infection, current and former smokers who have lung disease when they're smoking have worse outcomes than non-smokers. This is mainly shown in China for patients who had pre-existing pulmonary disease and co-existing chronic illnesses. We have no evidence, as far as I know, about the relationship between vaping and COVID, how much it harms, if at all. And that's it. Ready to have questions now. Thank you, Dr. Torres. So thank you so much for an interesting presentation, Dr. Schroeder. You shared so much with us. Before we shift to question and answer, we'll be there in a couple seconds. I want to take a moment to let our audience know that SMI Advisor is accessible also from your mobile device and smartphone. You can use the SMI Advisor app to access resources, education, upcoming events, complete mental health rating scales like the PHQ-9, and even submit questions directly to our team of SMI Advisor experts. You can download the app now at smiadvisor.org app. So now we'll jump into question and answer. We already have several submitted, but if you have more, you can put them in right now. And the first question is about vaping, which I know you covered, Dr. Schroeder. In general, people are saying, if you have a first episode psychosis program for younger patients, and what would be your kind of hot take or recommendation? What do we tell patients before all the evidence has come out around vaping, especially younger ones? So I'm going to answer for smokers in general, for people who do, for adults who don't vape, and then for young people, because it's a complicated, this is an extreme, vaping is extremely controversial, and it's fractured the public health people in this country. Let me give the overall narrative. So people who feel vaping is really bad, rightly point to what's been a big epidemic of vaping among young people, meaning some have become addicted to the vaping, to the nicotine, and others to be distracted to do less well in school. Some people worry that vaping among youth is a gateway to smoking, but we have the phenomenon that at the same time vaping has gone up, smoking of combustible cigarettes among youth is at a modern low. So it doesn't look on a population level that there's a gateway. The other thing is that vaping devices are used by a lot of kids for cannabis. So they're smoking weed, not the basic nicotine that's in the pods such as Juul. For adults, we know that the inhaling basic nicotine by itself is probably not that harmful, but the ingredients in the vaping, and there are about 70 of them, including the flavors, may be harmful to the lung. A lot of people in the UK, they think they're only 5% is harmful. Many people in the United States think they're more harmful. They're clearly a lot less harmful than smoking. So my counsel to people who are smokers is try standard nicotine replacement therapy or the two oral drugs I mentioned with counseling. If you're unwilling or unable, and you want to try vaping, try it, but don't both vape and smoke cigarettes at the same time. Switch to exclusive vaping and then try to get off. For young people, the data on how to quit vaping are unclear. Many of them are only episodic vapors, but there are a trouble group that are vaping on a regular basis, on a daily basis. Parents are very concerned. The Truth Initiative, which is a not-for-profit group based in Washington, which does anti-smoking large marketing, has on its website a way to help smokers quit, but there are no medications that I know of that have been tried for that. So that's a complicated answer, but it's a very complicated question. But also very practical, the way you broke it down. So thank you. I think that's the type of information people want, right? Hands-on what you can do. And a related, well, kind of different question saying there's a lot of websites and resources for smoking cessation you told us about to quit hotlines. Where do you, when you see patients recommend them, especially in the pandemic now, we can't get people handouts or things. Are there kind of authoritative, great educational websites or online resources beyond just a quitline that you like to point patients to, to help? Well, first of all, the quitlines are really underused and they're free. And if you're home, try them. So I would really urge that you, as mental health treaters, send patients to the quitline. Smokefree.gov is the U.S. Health and Human Services website. And it's really good. American Cancer Society, the Campaign for Tobacco-Free Kids. There are lots of websites that have these. Many states do. But I would really put in a plug for the quitlines. They're really terrific. And they're funded for most states from the tobacco taxes. So your tax revenue is put to very good use. That makes, it sounds like that is the resource to send people to as their frontline. This is a slightly long question, but I said, I think it's very important. It starts with how important is it for providers to assess willingness to quit in order to better understand the actual stage of change, which can again, help us better tailor and therefore, to more effectively intervene. So, or is it better to just kind of assess? So how important is it to really kind of assess the willingness to quit and kind of personalize it? Or what are, what is next as it relates to this assessment that the commission can do, assessing the skill level? So this question is sophisticated and understands the stages of change, which starts, this is a Prochaska paradigm. It starts with pre-contemplation. That is the smoker isn't willing to think about quitting. Contemplation, which means I'm thinking about quitting and then actually trying and then maintaining them off. So what you want to do is move them along that continuum. And one of the things you can do is something called motivational interviewing. So if your smoker doesn't want to quit, you can engage them with questions like, tell me why you smoke? What do you get from it? Are there reasons you can think of why you might not want to smoke? To engage them in debating whether they might want to do it. If they're contemplating, then you can think, well, that's interesting. You're thinking of quitting. Why do you think you want to quit? What's going to be hard about it? And move them along. To give someone in the pre-contemplation phase a prescription for NRT isn't going to help much. They're liable to throw it away. So what you want to do is ascertain. And some smokers are so embarrassed that they may actually, particularly pregnant women, may actually lie to their providers and downplay their smoking or give you a false impression that they want to smoke more. So motivational interviewing, where you're presenting yourself as very sympathetic for the smoker, and you really want to know where they are, is much better than being judgmental. I know that's hard for many clinicians because we understand how bad smoking is, and we think it was a bad choice. But that's my answer. And my comment to the questioner, because it shows a lot of underlying basic knowledge about how you get changed. By the way, that same thing about changing personal behavior holds true for exercise, weight loss, drug abuse, alcohol, those sorts of things. And then a question about when patients with serious mental illness may come into the inpatient hospital, often it says we may start them on NRT. Do you think it's ever better to start people on medications? Or what is kind of the best practice to do if someone is interested in quitting, they're in the inpatient hospital where they can't smoke? Is it time to kind of be more aggressive with treatment or to wait for outpatient? Well, I think it's a great opportunity. There's so much great opportunity. What I would do is outline, these are the ways we can help you smoke. Work with me to pick what you think would work best. So is it vermiculine? Is it the patch and oral? It's a great opportunity to get a twofer, to treat the underlying basic condition and to enlist their help in picking a treatment plan. But it's not too early. It used to be thought that it was, oh my gosh, this is a lesser concern. And that was at a time when, if you can believe this, cigarettes were bartered for sex, were used as a reward by hospital staff for good behavior in psychiatric hospitals. Clients and treaters, therapists smoked together outside. So we've come a long way, maybe to paraphrase the old pro-smoking ads for women. No, the field is definitely progressing. So that may wrap it up for time we have for question answer, but the good news is if anyone has follow-up questions about this topic or anything related to evidence-based care for SMI, our clinical experts are now available for online consults. Any mental health clinician can submit a question, receive a response from one of our SMI experts. The consults are free and always confidential. And as all of you hopefully know or we want to share with you, an SMI advisor is just one of the many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We encourage you to explore the resources available on the mental health addiction, the prevention TTCs, as well as the National Center for Excellence in Eating Disorders and Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opiate epidemic and more. I want to again thank our speaker, Dr. Schroeder, and thank all of you for joining. Until next time, take care.

Dr. John Torres

SMI Advisor

webinar

Smoking Cessation for Persons with Serious Mental Illness

Dr. Steve Schroeder

smoking cessation

mental health

healthcare providers

nicotine replacement therapy

COVID-19