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Vital Signs Telebriefing on Cigarette Smoking among Adults with Mental Illness

Tuesday, February 5, 2013 at Noon E.T.

OPERATOR:  Welcome and thank you for standing by.  At this time you're in listen only mode.  During the question and answer session, you may press star one to ask a question.  Today's conference is being recorded.  I’ll turn the call over to Mr.  Tom Skinner.  You may begin sir.

TOM SKINNER:  Thank you all for joining us today for another release of a CDC Vital Signs.  This one is on current cigarette smoking among adults with mental illness.  Today we have Dr. Tom Frieden, the director of the CDC, as well as Mr. Doug Tipperman from the Substance Abuse and Mental Health Services Administration.  Both will provide opening remarks and then we'll get to your questions.  Dr. Frieden. 

TOM FRIEDEN: Good morning or afternoon, everyone.  Thanks very much for joining us.  The topic today is a very important one.  We're talking about smoking among people with mental illness.  And we're releasing a report along with our federal partners at SAMHSA, both of these reports highlight data from SAMHSA's National Survey on Drug Use and Health.  We've joined today to call attention to a very serious health issue that needs more attention.  Specifically people in the U.S. with mental illness are 70 percent more likely to smoke than people who don't have mental illness.  As a result, they're at much higher risk for early death and significant health problems.  While cigarette smoking has declined, it remains the leading cause of preventable death in this country.  All smokers have more smoking related sickness and a life expectancy of ten years less than those who don't smoke.  Many people with mental illness are at greater risk of dying earlier from smoking than dying from their mental health condition.  This is a big mental health disparity and a vulnerable population and we need to do more for smokers with mental illness to quit. 

The analysis of today’s Vital Signs used combined data from SAMHSA’s 2009 to 2011 National Survey on Drug Use and Health.  For this analysis, respondents were considered to have a mental illness if they reported having a mental, behavioral or emotional disorder in the past 12 months.  This excluded developmental or substance abuse or addictive disorders.  During 2009 to 2011, about 36 percent, more than one out of three U.S. adults age 18 or older with mental illness were current smokers.  That compared to about one out of five or 21 percent of U.S. adults without mental illness.  The high prevalence of smoking in this population is a big public health problem and it also presents a significant economic burden.  About one out of five, 20 percent, of U.S. adults have some form of mental illness by this definition.  That's 46 million Americans.  That means that if adults reduce -- if efforts to reduce adult smoking are to be successful, we have to better address smoking among people with mental illness. 

Among those with mental illness, smoking rates were especially high among younger adults, American Indians and Alaskan Natives, those living below the poverty line and those with lower levels of education.  This difference was seen across every state in the country.  And it ranged from 18 percent in Utah to 49 percent in West Virginia.  On average, adult smokers with mental illness also tend to be heavier smokers.  During 2009- 2001, adults with mental illness smoked about three out of every ten cigarettes smoked by U.S. adults, that's 31 percent.  This is lower than estimates in the past which have included people with addictive disorders or substance abuse disorders, but the data is about the same. That not only are people with mental illness more likely to smoke, but they smoke more heavily.  As a result, they consume a large proportion, a disproportionate proportion of cigarettes smoked in this country. 

But despite all of this, smokers with mental illness, like other smokers, want to quit and can quit.  Treatments to help people stop smoking work.  And they're not as widely used as they should be.  Mental health facilities can help by making their campuses both smoke-free and tobacco-free, not allowing smoking or tobacco use among either patients or staff.  In the past, some mental health care providers and facilities have been reluctant to address tobacco use in their patients because they did not consider this a priority and they were afraid it would interfere with mental health care.  But that's not the case and those attitudes are changing.  We need to continue to raise awareness and collaboration between mental health and tobacco control programs and track the effectiveness of programs to help people with mental illness to quit.  It's been 50 years since the first surgeon general's report on the dangers of smoking.  And it's time that everyone is offered the help they need to quit smoking. 

Before I turn the call over to Doug Tipperman who is from SAMHSA's Center for Substance Abuse Prevention, I do want to relate one story from my own career.  My very first job was as an aide in a psychiatric hospital.  It was a long time ago, and in that job, the staff used cigarettes as a form of behavior modification for patients.  So if patients behaved better, they got additional cigarettes.  That legacy of tobacco and mental illnesses is one of the reasons we have a higher rate of smoking among people with mental illness.  But whatever the reason, anyone who smokes can quit.  Most Americans who have ever smoked have already quit.  And many people with mental illness who have ever smoked have already quit.  So I'm confident that we will do even better in future years reducing smoking, including among people with mental illness.  Doug, over to you. 

DOUG TIPPERMAN: Thank you, Dr. Frieden.  I'm pleased to be here today to bring attention to this important health issue.  Previously published research in some medical journals has shown that rates of cigarette use among persons with mental illness have been significantly higher than rates among people who do not have mental illness.  SAMHSA's report, Smoking and Mental Health, looks at three years of survey data to provide an update on the relationship between smoking and mental illness.  As mentioned before, the smoking rate among those with a mental illness is 70 percent higher than among those who do not have a mental illness.  Are those with mental illness able to quit smoking?  Our study shows that, yes, they do quit, but at lower rates than those without mental illness.  About one in three adults with mental illness who had ever smoked had quit compared to more than one-half of adults without mental illness.  Proven approaches are available to help reduce tobacco use among Americans with mental illness.  Mental health care providers can play a key role in helping smokers with mental illness quit by routinely asking their clients if they use tobacco and providing evidence based cessation treatments to those who do. 

Tobacco cessation treatments can be integrated into mental health care without disrupting that care or jeopardizing patients' recovery.  Persons with mental illness face challenges in trying to quit and may benefit from additional counseling, longer use of cessation medications, and monitoring as part of this routine care.  This can include monitoring the dosage of their psychiatric medications which can be effected by smoking cessation.  However, contrary to traditional perceptions, smokers of mental illness are interested in quitting, are able to quit and benefit from evidence-based cessation treatments.  To address the high rates of tobacco use among persons with mental illness, SAMHSA in partnership with the Smoking Cessation Leadership Center has developed a portfolio of activities such as the 100 Pioneers for Smoking Cessation Campaign which began in 2008 and provides support to mental health facilities and organizations to undertake tobacco cessation efforts.  This support has included financial awards, technical assistance, networking and training webinars. 

In 2010, SAMHSA and the Leadership Center expanded the Pioneers Campaign by working with states through leadership academies for wellness and smoking cessation.  The goal of the academies is to reduce tobacco use among those are mental illness.  Participating states bring together policymakers and stakeholders including leaders in tobacco control, mental health, substance abuse, public health and mental health consumers to develop a collaborative action plan.  Today we're publishing these survey results so that policy makers, mental health practitioners and public health service providers can use this information to better understand and address the needs of those with mental illness to make progress in lowering rates of smoking.  Thank you and this concludes our opening remarks. 

TOM SKINNER:  Shirley, I believe we're ready for questions, please. 

OPERATOR:  Thank you.  We will now begin the question and answer session.  If you would like to ask a question, please press star one.  Please unmute your line and record your name clearly.  To withdraw your request, you may press star two.  Again, press star one to ask a question.  One moment, please, for our first question.  Our first question comes from Mike Stobbe with the Associated Press. 

MIKE STOBBE: Thank you.  Thank you for taking the question.  I had two.  First Mr. Tipperman, I think you said that people who have mental illness are interested in quitting.  Do you mind giving a little more information about where that comes from?  Was that a survey and what the results were and also I wanted to ask, these results my understanding is that the survey does not include people who are institutionalized.  Could you all talk a little bit more about how many Americans are in mental illness institutions and psychiatric hospitals and what proportion of those facilities are smoke-free or have smoking limitations or rules in place? 

DOUG TIPPERMAN: This is Doug Tipperman.  The information about wanting to quit, I'm not sure if that comes from a survey, but it's something that we hear frequently from the field.  There was a large mental health facility in Indiana that serves about 7,000 patients and they instituted tobacco cessation efforts and they were surprised that a lot of the feedback they got from their clients is “no one has ever asked me before if I wanted to quit.”  So in places that are implementing these strategies and policies, we're finding that there really isn't much resistance or push back from clients.  As a matter of fact, it tends to go the other way.  I think they also are appreciative people are concerned about their health and well-being.  You asked a lot of questions about data and some statistics.  And we would be glad to follow up with you if you'd contact us after the call.  I'd be glad to share my phone number at the end of the call. 

MIKE STOBBE: Okay.  Thank you. 

TOM FRIEDEN: And this is Tom Frieden at CDC.  There is also evidence in the published literature, not from this survey but from others, that as many as 77 to 79 percent of people with mental illness intend to quit and many of them intend to quit in the next month and we can get you the references for that if you'd like. 

MIKE STOBBE: Thank you. 

OPERATOR:  Thanks.  Our next question comes from David Beasley with Reuters News Service.  You may ask your question. 

DAVID BEASLEY: Yes, I was wondering is there any overarching reason why people with mental disabilities smoke more?  In other words, is there some sort of perceived calming effect from tobacco or in general -- I know there are probably lots of reasons but I was wondering in general is there one particular reason why they smoke more? 

TOM FRIEDEN: I’ll start.  This is Tom Frieden at CDC.  There are challenges for people with mental illness.  For people with certain mental illnesses, there's a higher rate of smoking initiation and there are some effects of nicotine which can mask some of the negative effects of mental illness.  That said, it's still the case that although quitting is difficult for many smokers, it can be especially difficult for smokers with mental illness.  So what Mr. Tipperman noted earlier, most people without mental illness who have ever smoked have already quit.  More than 50 percent.  But only about 34 percent of those with mental illness who have ever quit -- who have ever smoked have already quit.  So there's a lower rate of quitting among those with mental illness.  The initiation rate may be a little higher for some subgroups, but the quit rate is substantially lower.  And that may be for a variety of reasons.  It may be because they lack financial resources or health insurance or information about the benefits of quitting, or because there's been specific tobacco industry marketing to populations with mental illness.  Some of that marketing has shown that there may be some effect of nicotine on some of the mood problems associated with mental illness.  But of course there are very effective medications and therapies which treat mental illness without taking ten years off your life. 

DAVID BEASLEY: One follow-up question.  Did I understand correctly that the rates of smoking on the mentally ill are staying the same, they haven't gone up or down? 

TOM FRIEDEN: This data is only one-time data, so we can't comment from the report we're releasing today about the trends. 

DAVID BEASLEY: Okay.  I thought earlier you mentioned that if you take the drug addicted people out of the mix, then the numbers are pretty much the same as they have been.  I might have misunderstood that. 

TOM FRIEDEN: I'm not sure we understand your question. 

DAVID BEASLEY: I thought earlier you said if you take -- the previous surveys have included drug addicted patients and this survey took those out of the mix, is that correct? 

TOM FRIEDEN: Let me clarify.  I was referring to one particular statistic which is the proportion of all cigarettes smoked by people with mental illness, which in this report is about 31 percent.  In prior reports, it's been higher because it included people with both mental illness and drug addiction. 

DAVID BEASLEY: You can't say just mental illness whether it's going up or down? 

TOM FRIEDEN: We can't say that from this data.  If you can hold on just one moment. 

DOUG TIPPERMAN: There was a report put out by New York state, they did a survey there that came out about a year ago where New York state, they found that smoking rates over the past decade did not change significantly for those with mental illness.  However, it did decline in the general population or those without mental illness. 

DAVID BEASLEY: Okay.  Thanks. 

OPERATOR:  Thank you.  Our next question comes from Timothy Martin with Wall Street Journal. You may ask your question. 

TIMOTHY MARTIN:  Hi.  Thanks for taking the call.  I have a two part question.  First one is you had mentioned there was an approach to cessation that smoking and the types of medications that people with mental illness are on, that it could affect dosage levels.  Could you talk about that more?  And secondly, is there -- could you present any type of examples of tailored programs I guess?  It seems like the research and findings today suggest the current slate of cessation programs need to be amended somehow or tweaked somehow or to include a broader group of marketing or targeting to really capture this group.  Thank you. 

TOM FRIEDEN: I’ll start -- This is Tom Frieden at CDC -- with your second question and turn it over to Mr. Tipperman for the first question.  In terms of smoking cessation treatments, they work including for people with mental illness.  They're just not used nearly as often as they should be.  So both medication and counseling and there are a number of effective medications are greatly underutilized among people who want to quit.  Virtually every adult, non-pregnant adult, who wants to quit smoking should be on one medication to help them quit or not if any want to double or even triple their chance of success.  People with mental illness may require longer treatment and if they're in treatment facilities either residential or day programs, it will be very helpful for them for those facilities to be completely smoke free and tobacco free.  That will increase their likelihood of success.  There are a variety of programs that have worked with people with mental illness to encourage quitting.  What we generally find is that treatments work; they're just not being applied as widely as they should be.  There may be a need for longer term treatment for some people with severe addiction to tobacco. 

DOUG TIPPERMAN: The results of a study done by the veterans administration with PTSD patients, what they found was that when the smoking cessation program was integrated into the routine care, their clients were much more likely to be successful in quitting their tobacco use. 

OPERATOR:  Our next question comes from Carl Campanile with the New York Post.  You may ask your question. 

CARL CAMPANILE:  Greetings.  Dr. Frieden, how are you? 

TOM FRIEDEN: Fine, Carl.  Nice to hear your voice. 

CARL CAMPANILE:  Good to hear you.  I want to circle back to the question of why the smoking is heavier or there's a higher rate among the people who have mental illnesses.  I just want to try to put it in layman's terms.  Are there stress factors involved?  And I just want you to go back when you mentioned in the beginning of your statement about when you started out, I believe you said in a psychiatric facility, institution, that cigarettes were used or tobacco was used as some sort of reward system.  Just wanted to see if you could elaborate on that a little more. 

TOM FRIEDEN: For many years, cigarettes were used in mental health facilities.  This goes back to the '70s in my case where i worked as an aide in a psychiatric hospital.  So it's a while ago.  But still there is a tradition of being less attentive to the physical health of people with mental illness in some mental health care services.  And we know that for people who smoke, quitting smoking is the single most important thing they can do to live a longer and healthier life.  The overall reason is that a greater proportion of people with mental illness who started to smoke haven't yet quit.  Now, the reasons they haven't quit are several.  One is that they may on average related to their mental illness smoke more heavily than people without mental illness.  And it's harder for people who are heavier smokers to quit than it is for people who are lighter smokers to quit on average.  Though anyone can quit.  A second reason is that people with mental illness have not always gotten the services they need to help them quit.  A third reason may be that there are some aspects of tobacco use which alter some aspects of some mental illness.  Anxiety disorders for example.  But again, there are very good treatments and very good counseling that unlike cigarettes don't take ten years off your life and have all of the other serious health consequences of smoking. 

CARL CAMPANILE:  Okay.  Thank you. 

OPERATOR:  The next question is from Elise Viebeck with The Hill.  You may ask your question. 

ELISE VIEBECK:  I just wanted to circle back to the definition that we're using.  Dr. Frieden, I know you said that people in the survey had reported a mental behavioral or emotional disorder in the last 12 months.  Were those clinical diagnoses, or could it just be someone who reported feeling anxious or depressed?  Thank you. 

TOM FRIEDEN: This is a house to house survey, and it asks about the preceding 12 months, asks a series of 14 questions that are in two validated scales.  So the combination of those scales was used to determine based on a statistical model from the clinical interviews whether respondents met the definition of having a mental, behavioral or emotional disorder.  And that doesn't include either developmental or substance abuse disorders. 

ELISE VIEBECK:   Okay.  Thank you. 

TOM FRIEDEN:  Does that answer your question? 

ELISE VIEBECK:   Yes, it does.  Thanks. 

OPERATOR:  Again, if you have a question, press star one.  Our next question comes from Jaclyn Cosgrove with Oklahoma Watch.  You may ask your question. 

JACLYN COSGROVE: Hi.  I'm actually with the Oklahoman.  Oklahoma has one of the highest smoking rates in the nation.  And thus we have one of the highest -- we also have one of the highest smoking rates among people with mental illness.  I was wondering if you saw any sort of correlation with other states that had high smoking rates and high smoking rates around people with mental illness or if you saw states with lower smoking rates but still high among people with mental illness. 

TOM FRIEDEN: Generally we see it's consistent.  If smoking is more common in a state, it's more common among people with mental illness in a state.  If it's less common, it's less common among people with mental illness in that state.  There are some differences by race ethnicity of smoking rates generally both among people with and without mental illness.  American Indians and Alaskan Natives have much higher rates of smoking and people with lower educational attainment or below the poverty level have higher rates of smoking. 

OPERATOR:  Next question comes from Karen Herzog with Milwaukee Journal.  You may ask your question. 

KAREN HERZOG: Thank you for taking my question.  The state of Wisconsin is similar to other states in that it only spends a very small portion, one penny of every tobacco dollar that it takes in in taxes, on programs for cessation and prevention.  And I’m wondering what your thoughts are on whose responsibility is to help people quit smoking and should more of the money that states bring in from taxes and from the tobacco settlement, the big smoking of -- big tobacco companies, how should the funding come down? 

TOM FRIEDEN: State governments receive much more money in tobacco tax receipts and settlements from the master settlement agreement than they spend in tobacco control.  In fact, tobacco control is outspent by the tobacco industry by many, many times over.  And that's one of the reasons that we've had a virtual stall in the decrease in smoking in the United States.  Tobacco control works.  Tobacco is the leading preventable cause of death in this country.  More than 1,000 Americans every day are killed by tobacco.  And a disproportionate number of them are people with mental illness.  But people from all walks of life, all states in the country, all demographic groups are dying younger, being sicker, spending more money in health care because we're not doing as we as we could investing in tobacco control.  Tobacco control services work.  They reduce smoking rates and they save lives.  We have time for one more question if there is one. 

OPERATOR:  I’m showing no further questions. 

TOM FRIEDEN: Okay.  So just to wrap up, thank you all very much for joining.  The bottom line here is that today's information released in concert with the substance abuse and mental health services administration shows that people with mental illness are much more likely to smoke.  They're much less likely to have quit.  But people with mental illness who smoke want to quit and can quit and we need to do a better job of getting services to people with mental illness and others so that everybody who wants to quit can.  Thank you very much.  

TOM SKINNER:  Thanks, Shirley.  This concludes our call.  We'll have a transcript of this call available through the CDC media relations website later this afternoon.  If reporters have follow-up questions, they can call the CDC press office, 404-639-3286. 

DOUG TIPPERMAN: This is Doug Tipperman.  I would like to offer a number for SAMHSA if people would like to follow up with us.  I’ll give out my number.  240-276-2442. 

TOM SKINNER:  Okay.  Thank you all for joining us.  

OPERATOR:  Thanks and this does conclude today's conference.  We thank you for your participation.  At this time, you may disconnect your line.  

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