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JAIMEE HEFFNER: This is Jaimee Heffner.

I'm an assistant member in the Division of Public Health

Sciences at Fred Hutch.

And my research program focuses on improving tobacco treatment

outcomes for smokers with mental health conditions.

In this talk, I'll provide some background

on why this is such an important area for research and practice.

I'll start by focusing on the prevalence and consequences

of smoking among people with mental health conditions.

I'll then review barriers to tobacco treatment

in this population.

And then I'll discuss interventions

for addressing tobacco dependence among people

with mental health conditions.

The high rates of smoking among people with mental health

conditions is unmistakably a health disparity.

Simply, the definition of a health disparity

is when differences in health outcomes or health determinants

are observed between populations.

I'll briefly discuss why I believe

that to be an accurate description when we consider

the characteristics of the smoking population

in the United States today.

But there's a great article in the American Journal

on Public Health that provides a more comprehensive discussion

of this topic.

So these are data from the National Comorbidity Survey,

which shows lifetime rates of ever-smoking in people

without mental illness as well as in people with major Axis I

disorders and antisocial personality disorder.

All the way on the right is the prevalence

of ever-smoking among people with no mental illness, which

is around 40%.

As you can see, lifetime rates of ever-smoking

tend to be higher in all of the major categories

of mental health conditions compared to no mental illness.

This chart shows the proportion of ever-smokers

in each diagnostic category who successfully quit.

Again, you can see that the rates tend

to be lower among people with many

of these psychiatric disorders compared

to people without the psychiatric disorder.

And the roughly 16% of individuals

with bipolar disorder who successfully quit

is particularly low.

So to summarize, there tend to be high rates of smoking

and very low rates of successful quitting in people

with psychiatric disorders compared to people

without the disorders.

What's worse-- the disparities in exposure

to the effects of tobacco smoke aren't changing over time.

And there are even some indications

that it's getting worse.

For example, these are data on change

and the prevalence of smoking in New York state,

among those with good mental health versus those

with poor mental health.

For those with poor mental health,

between 2000, 2001, and 2008, 2009,

there was no significant change in smoking prevalence.

For those with good mental health,

there was a significant 25% decrease

in the prevalence of smoking.

So the gap is getting wider.

And the status quo just isn't going to work to change this.

So it's time that we change course and do

something different for smokers with mental health conditions.

You probably are already aware of the many devastating effects

of tobacco use in general.

So as I talk about consequences of smoking,

focus primarily on consequences in the context of having

a mental health condition.

For example, these are data from a study that

examined death records of people who

had completed an inpatient addictions treatment program.

And this was 20 years after they completed it.

Now, you might expect to see really high rates of deaths

from alcohol-related causes in this population.

But one of the key findings from this study

was that these individuals were more

likely to die from tobacco-related causes

than they were from alcohol-related causes.

So even though tobacco use is often

treated like a secondary problem or not treated at all,

it's the behavior that's most likely to kill

the people that we see in addictions treatment settings.

One of the dangers of smoking among people with alcohol use

disorders is that the risks of combined use

are multiplicative, rather than just additive

in the case of cancers of the head and neck.

So as an example, this table shows

the odds of developing laryngeal cancer from heavy smoking

alone, and the alcohol use alone,

and the combination of heavy smoking and drinking.

The odds ratios in the right column

mean that compared to nonsmokers,

heavy smokers have 43 times higher odds

of developing laryngeal cancer.

Heavy alcohol users compared to nondrinkers

have about six times higher odds of developing laryngeal cancer.

And those who smoke and drink heavily compared

to nonsmoking nondrinkers have 177 times

higher odds of developing that type of cancer, which

is a multiplicative increase compared

to the individual risks of heavy smoking and heavy drinking.

Another study looked at state-level data

on deaths among consumers of public mental health services

compared with the general population in that state.

And what they found was on average,

the individuals with mental illness died up to 20

to 30 years earlier than the general population.

And it wasn't for the reasons that you might think,

like suicides or accidents, which do happen

at higher rates in this group.

It was from things like cancer and cardiovascular disease,

which are very similar to the causes of death

in the general population, yet they're

happening decades earlier.

And the question is, why?

And we can't say for certain, but it certainly

suggests that behavioral factors are involved, like smoking

being a key one of them.

Another consequence of smoking for people with mental health

conditions is a financial one.

With the cost of cigarettes about $5 to $10 per pack,

depending on where you live, people

who smoke a pack or more a day are spending a few hundred

dollars a month on cigarettes.

And for people who live on low-incomes or no incomes,

this is a really heavy financial burden.

One study of smokers with schizophrenia

showed that participants were spending on average

about a quarter of their monthly income on cigarettes.

It's important to remember that from a public health

perspective, as cigarette prices go up,

smoking prevalence tends to go down.

But the most vulnerable people who are heavily addicted

and can least afford it are going

to continue to spend increasing amounts of their income

to get cigarettes.

And they may not have access to resources to help them quit.

Another consequence that's specific to people

with psychiatric disorders is the effect

of tobacco smoke on levels of some psychotropic medications,

including those seen in this table.

So this effect is due not to nicotine itself,

but to a chemical in tobacco smoke

called polycyclic aromatic hydrocarbons.

And those are chemicals that affect

the metabolism of medications by acting on the cytochrome P450

system.

Now, in some cases, like in the case

of olanzapine or clozapine, the plasma levels of the medication

may be reduced by as much as 50% as a result of smoking.

What that means is that smokers may need higher

dosages of these medications.

And when they reduce or quit smoking,

they may experience increased side effects

from having higher levels of the medication.

There are also a number of case reports

in the literature of people being stabilized

on one of these medications while hospitalized,

either in a nonsmoking or a restricted smoking environment.

And then once they get out, they destabilize,

because the tobacco smoke has effectively cut the medication

dose in half.

Hopefully, what I've imparted so far

is that there are many negative consequences

of smoking and many benefits of quitting for people

with psychiatric disorders.

Of course, there are a number of factors that can potentially

make it more difficult for people with these disorders

to quit.

For example, on average, smokers with mental health conditions

tend to have started smoking earlier in life.

They smoke more heavily.

They're more likely to be nicotine dependent.

They have higher rates of use of other substances.

And they're exposed to more smoking

cues in the form of being around other people who are smoking.

To illustrate that last point, this

is a quote from a participant in one

of our smoking cessation studies, which was specifically

focused on people who are in substance use disorder

treatment.

This person said, "Quitting smoking

is really a two-step process.

First you stop smoking your own cigarettes,

then you stop smoking everybody else's."

There was a certain camaraderie among the smokers

in this treatment program.

And it went without saying that if someone

didn't have a cigarette, you would offer them one of yours.

And you can imagine how that would make it very difficult

to quit in that environment.

There have been a few studies looking at tobacco

treatment-related practices of individuals

who provide mental health or substance abuse treatment.

And I listed just a couple of them

here, which happen to focus on psychiatrists

and psychologists.

Looking at psychiatrist practices,

one study found that tobacco cessation counseling was

offered only in 12% of visits.

And pharmacotherapy is only in-- none of the visits.

In another study, focusing on psychologists, only 29%

of the respondents said that they systematically

assess tobacco use.

And only 31% routinely advise tobacco users to quit.

Finally, on an organizational level,

the extent to which mental health and substance use

disorder treatment programs are putting

tobacco treatment into their programming is still lacking.

For example, less than half of substance

use disorder treatment programs in the United States

provide tobacco treatment to their clients.

There are a number of reasons why tobacco treatment isn't

being addressed as part of mental health treatment.

For one, tobacco use doesn't fall squarely

into the domain of any one type of treatment provider, which

creates sort of a diffusion of responsibility,

thinking that somebody else will take care of it,

and it's not really my job.

So a psychologist or a psychiatrist

who has a limited time to see the person might be thinking,

well, I'm going to focus on the primary mental health problem

here and not on the tobacco use.

I'm sure the primary care provider

we'll talk to them about that.

Of course, they may or may not have a primary care provider.

Or that person may be focused on other things

and may also be thinking, well, I don't have a lot of time

for this, so I'm going to let someone else discuss that

with them.

A perceived lack of training is one of the most prevalent

provider barriers.

And it's true that tobacco treatment is not

covered in the way that it should be in mental health

providers training.

If they're lucky, they might get something

like an hour-long in-service on this topic.

The key, I think, is to help providers understand

that they already have the skills

that they need to help tobacco users quit.

They just have to put them into action.

Another major barrier is if the provider is a smoker.

The one study of substance use treatment program

showed that the staff who smoked were

six times less likely to intervene with client smoking.

Providers also report challenges around not having enough time

to add tobacco treatment under their treatment plan

and not being able to bill for that time, which

is a financial disincentive.

Additionally, providers have some beliefs

about smoking in mental health that can be problematic.

An example would be the belief that smokers with mental health

conditions don't want to quit, or that they can't quit,

even if they want to.

Also, overvaluing the benefits and undervaluing the harms

of tobacco use has a long history

in psychiatric and substance abuse treatment settings.

And let me just provide a few examples of that.

"A cigarette break can be all that's

needed to regain one's composure, relax for a moment,

and prevent internal overstimulation."

This is a statement from a leading

text on cognitive behavioral therapy for bipolar disorder.

The idea here seems to be that smoking

is an acceptable and effective form of coping.

And if that idea doesn't seem so bad to you,

just try replacing the word cigarette with alcohol here.

Here's another one from a letter written

by a psychiatrist to RJ Reynolds to request

a donation of cigarettes.

"Providing a cigarette is generally

much more effective at decreasing agitation

than most medications I can provide."

The message here is that cigarettes are a medication

and not just any medication.

The most effective medication that this person

has at their disposal.

Again, this is an example of overvaluing the benefits

and undervaluing the harm.

"If you could, by some miracle, donate cigarettes or tobacco

to the hospital to the patients, it

would be very much appreciated.

As you know, it's very hard to stop smoking.

And for some here, it's all they have.

A majority of the patients here do not

have family who are involved or care enough about them

to bring cigarettes to them."

The message here is that providing cigarettes

is an indication of caring.

It also suggests that cigarettes are

the only thing that patients have going for them.

And an interesting note about this quote

is that this letter was sent right

around the time of the congressional testimony that

resulted in the major tobacco companies

paying enormous settlements to the states

after they testified one by one that they believed tobacco was

not addictive, even though their internal research suggested

otherwise.

If only they had read this letter first,

they would have known what this person clearly noted.

That smoking is an addiction.

"Imagine the police have just taken you in handcuffs

to the psychiatric emergency room of Bellevue Hospital.

You've been hearing voices, and your life

has stopped making sense.

The doctor is trying to explain something to you,

but everything is confusing.

She tells you that you will be held against your will

until you're stabilized.

You're given medication for your psychosis.

You're nervous and scared.

You ask for a cigarette, one of your few pleasures in life.

The nurse sarcastically tells you

that you won't be able to smoke.

The hospital is smoke-free, and there are no discrete smoking

areas.

What has happened to individual freedom and respect

for the human dignity of New York City's

most vulnerable citizens--

the seriously and chronically mentally ill?

Why does Bellevue Hospital force psychiatric patients

to go cold turkey?

Please create a discreet smoking area

for all of your psychiatric patients."

Now, this passage suggests that being able to smoke

is somehow symbolic of dignity and autonomy.

This document was produced by the Alliance

for the Mentally Ill, which is a predecessor of NAMI.

Interestingly, this document was in the hands of a tobacco

industry representative, hence the indexing number

at the bottom.

And it's now part of the tobacco industry documents.

Also, interestingly, the Alliance for the Mentally Ill

denied any connection with the tobacco industry.

Yet a handwritten note from one of its board members

was also part of the documents that were turned over

as part of the settlement.

These gentlemen are the two co-founders

of Alcoholics Anonymous, William Wilson and Robert Smith.

Also, known as Bill W. and Dr. Bob.

Both of them were smokers.

Bill W. smoked cigarettes, and Dr. Bob smoked cigars.

Both of them also died from smoking-related causes--

Bill W. from emphysema and Dr. Bob from throat cancer.

And their attitudes towards smoking

are reflected in some of the writings that

are still used today in AA.

For example, this passage from The Big Book.

"Though he is now a most effective member

of Alcoholics Anonymous, he still smokes and drinks coffee.

But neither his wife nor anyone else stands in judgment.

She sees that she was wrong to make a burning issue out

of this matter when his more serious ailments were

being rapidly cured."

Now, this was written decades ago.

And to some extent, it's consistent with the culture

of that time.

However, elements of that culture

still persist in addictions treatment settings today.

Sigmund Freud was often photographed holding a cigar,

probably because of the frequency

of his youth, which was about 20 cigarettes per day.

Freud started having health problems like chest pain

and shortness of breath at the age of 30,

but he was unconvinced that it was due to smoking.

Freud went on to develop cancer in the soft tissue of his mouth

and jaw, which resulted in over 30

operations and a prosthetic jaw that he called the monster.

However, he was still not entirely convinced

that smoking was the cause of his cancer.

And he continued to smoke until his death at the age of 83.

At one point, with the urging of a friend who was a physician,

Freud did quit smoking, and this was the result.

"I have not smoked for seven weeks.

At first, I felt as expected-- outrageously bad--

cardiac symptoms accompanied by mild depression

as well as the horrible misery of abstinence.

These wore off, but left me completely

incapable of working.

A beaten man.

After seven weeks, I began smoking again.

Since the first few cigars, I was able to work

and was the master of my mood.

Before that, life was unbearable."

Now, to put all these puzzle pieces together

that I've been showing to you--

the idea that smoking isn't that bad, that it's the lesser evil,

that it's a form of self-medication--

these are all really firmly rooted

in the culture of psychiatric and substance abuse treatment.

And although that culture is changing,

it's hard to change really deeply entrenched ways

of thinking.

And these beliefs are still interfering

with people getting the help that they need to quit smoking.

There's also one more category of beliefs

that acts as a barrier to tobacco treatment

and I haven't talked about yet.

And that's the belief that quitting smoking

will be destabilizing, either in terms

of increasing symptoms or leading to drug

or alcohol relapse.

These beliefs are often based on anecdotal evidence,

and they don't hold much water when you look at the research.

For example, in a study of smokers with depression,

the depressive symptoms actually decreased after quitting.

Several studies have shown that symptoms of schizophrenia

are unaffected by quitting.

And in the largest study to date of smoking cessation for people

with post-traumatic stress disorder,

the findings show that the PTSD symptoms were

improved among people who quit.

The same pattern holds if you look at smokers with ADHD

and those with substance use disorders.

Quitting smoking either has no effects

on the symptoms or course of the disorder,

or it has a beneficial effect.

Bipolar disorder has not been well-represented in the smoking

cessation literature.

And for that reason, we analyzed data

from a naturalistic study of adolescents and adults

with bipolar disorder who were hospitalized

for a first episode of mania.

And they were followed for up to eight years

after this first hospitalization.

So to test the effects of quitting smoking on symptoms,

we compared changes in depression and mania symptoms

between smokers who quit for at least two months and those

who continued to smoke.

And here's what we found.

This first figure shows changes in mania

among the continuing smokers, which

is shown in blue versus the quitters shown in green.

Since there could conceivably have been differences

between adolescents and adults, the results

are shown separately by age group.

As you can see by the overlapping error bars,

we found no significant difference

between smokers and quitters in either the adolescent

or the adult age groups.

And the amount of change overall in the measure of mania

was really negligible.

The same pattern held for depression symptoms.

We saw very little change on average

and no difference between quitters and continuing

smokers.

So there's no evidence that quitting had a negative impact

on bipolar disorder symptoms, either in the adolescents

or in the adult smokers.

And this was a really exciting finding,

because it was the first study to show that quitting

smoking didn't worsen mood.

And that was a big barrier to quitting for people

with bipolar disorder.

Now, it's also worth noting that even

if we had seen an increase in symptoms of depression or mania

on these scales, it's possible that this

could have been attributable to nicotine withdrawal.

Many of those symptoms can mimic symptoms

of depression or mania.

So in this table on the left in bold

are the DSM-IV defined symptoms of nicotine withdrawal.

And the bulleted items in the depression and mania columns

are places where the symptoms overlap

with nicotine withdrawal.

As you can see, there's a lot of overlap.

And this touches on an important point

about smoking and mental health symptoms.

Clinically it can be really difficult to differentiate

withdrawal symptoms from psychiatric symptoms,

particularly in the early period of quitting.

However, nicotine withdrawal symptoms

should peak within the first week or two of quitting

and then decrease steadily after that,

so long as the person doesn't continue to smoke,

or use any other form of nicotine or tobacco.

If the symptoms are worsening over time,

that may be an indication that it's more

that nicotine withdrawal.

Also, if the symptoms are very severe--

for example, if the person can't get out of bed,

or if they're having suicidal thoughts,

those aren't likely to be nicotine withdrawal-related.

So far I've focused primarily on short-term changes

in mental health after quitting smoking.

But what about the long-term impact on mental health?

This is an epidemiologic study using NESARC data

to compare quitters to continuing smokers on--

at the top, development of new onset

psychiatric disorders among people

who have no history of them.

And at the bottom, recurrence of a psychiatric disorder

among people who do have a history

of having such disorders.

And this is over a three-year time period.

So in both the top and bottom panels,

we see evidence that quitting smoking

is associated with a lower likelihood of either developing

new onset disorders, or having a recurrence of an existing

disorder.

What we don't see is any evidence

of an increased risk associated with quitting smoking, which

would be an odds ratio of greater than one.

There have also been two meta-analyses,

which combine data across multiple studies which

have shown that mental health is not

worsened by quitting smoking and may, in fact, be improved.

One of these studies found that reduced negative affect

and stress, increased positive affect,

and improved psychological quality of life

among quitters compared to continuing smokers.

So in sum, it's time for us to let go of this myth

that quitting smoking is dangerous and risky for people

with mental health conditions.

Hopefully, by this point, I've convinced you

that smoking is a significant problem among people

with mental health conditions.

And that all of these barriers to treatment

are either myths, or things that can

be addressed through treatment.

Now, I want to move on to the question of how

we treat tobacco use, starting with general principles

of tobacco treatment and then talking

about specifics of treating smokers

with psychiatric disorders.

These are the general principles of tobacco treatment, which

are taken directly from the Public Health Service

guidelines.

What they suggest is that we need to think about tobacco use

more like a chronic disease than an acute one.

It's not something that can be cured in six to eight weeks.

In fact, most tobacco users try to quit

7 to 10 times before they finally quit smoking for good,

or quit using other tobacco.

We do have treatments that are effective at helping people

to quit.

And we have evidence-based methods

of working with people who are unmotivated.

So regardless of someone's readiness to quit,

some form of effective treatment is available,

and it should always be provided.

And that treatment doesn't have to be

20 hours of face-to-face time.

Even spending 10 minutes with someone

increases the likelihood that they'll quit.

And one of the best ways to make sure

that all tobacco users are getting the treatment they need

is to have a system in place within an organization,

including mental health care organizations,

to screen for tobacco use, and to provide treatment.

In terms of how much contact time is optimal--

up to a point, there's a linear increase

in quit rates associated with increased contact time.

And that point is about 90 minutes.

The content of the behavioral interventions

tends to be a mix of techniques.

But the practice guidelines suggest

that interventions that involve problem-solving or skills

training are effective, as is the support of the treatment

provider or a treatment group, which we call

intra-treatment social support.

Finally, there's very robust evidence that medications work.

And so all tobacco users should be

offered a medication in combination

with behavioral counseling.

And we know that the combination of medications and counseling

is better than either one alone.

Although people with psychiatric disorders

are not well-represented in the literature base that

supports these guidelines, there's

no reason to believe that these principles don't

apply to tobacco use or sociopsychiatric disorders.

However, there are some questions

that come up when thinking about how to provide treatment

for this population.

And I've listed some of the more frequently discussed ones here.

First of all, when is the best time

for someone with a mental health disorder to quit?

There are those who say that we should wait until mental health

symptoms are gone, or completely stable before intervening.

The problem is that some people have symptoms that

could come and go for years.

So they're never really stable.

So should smoking cessation be put off indefinitely?

I'm going to argue that the answer to that question is no.

And here's one big reason why.

Anytime you suggest delaying quitting for any reason,

you lose a window of opportunity.

And a good example of this was a study

by Anne Joseph and colleagues, which compared concurrent

versus delayed treatment for smokers who are in substance

use disorder treatment.

And that study showed that smokers were significantly more

likely to participate in the smoking cessation treatment

if it was offered at the same time

as their intensive treatment program

for a substance use disorder versus if they had to wait six

months until they were finished with the substance use disorder

treatment program.

Now, of course, there may be times

when a clinician decides to briefly postpone

discussion of tobacco cessation, like when

a patient is in crisis.

Another decision point about how to deliver treatment

for smokers with mental health conditions

is, who should provide the treatment?

And that choice often comes down to practical issues

like cost, availability, and individual preference.

The good news is that there are a lot of treatments-- treatment

options out there.

So everyone can find something that works for them.

I do want to point out that there

are many benefits to having treatment

provided by the same people who are providing mental health

care.

First, it builds off of a relationship that's already

been formed, so there aren't any falloff points

that come along with referring to an outside treatment

program.

A mental health provider also can

address the relationship between mental health symptoms

and smoking better than someone like a paraprofessional

quitline counselor, or a web-based program

that isn't designed for smokers with mental health conditions.

A very large trial done within the VA system

helps to show the promise of this approach.

So this study provided integrated tobacco cessation

with PTSD treatment and found that that approach doubled

quit rates compared to a standalone tobacco treatment.

Another question which is largely unanswered at this

point is whether targeted interventions that are

specifically designed for smokers with mental health

conditions are more effective than a one-size-fits-all

approach that is the current standard of care.

And as I mentioned previously, there

are a couple of categories of effective treatment--

medications and behavioral support.

So let me start on the pharmacotherapy side.

So there are seven FDA-approved medications

for tobacco treatment.

You have five different formulations of nicotine

replacement therapy.

There's bupropion, and there's varenicline.

And all three of these medications at least

double the odds of quitting compared to placebo.

In the case of combined NRT and varenicline,

it's closer to tripling the odds of quitting.

So if we use these medications in people's

psychiatric disorders, it's important to consider

not only the established safety and efficacy data if they exist

for the particular group, but also how they might interact,

or what side effects might alter the specific risk-benefit

ratio.

So for example, both bupropion and varenicline

have box warnings for risk of neuropsychiatric side effects.

So let's look first at where those warnings come from.

Warnings on the labels of drugs come

from post-marketing surveillance.

So FDA has a system to collect and evaluate

safety issues that are reported by health care providers

or consumers.

And the problem with relying on this method to determine safety

is illustrated in a story that I can tell you.

So this is a story of James Elliott who

is an Army veteran with PTSD, who enrolled in a VA study that

was testing varenicline for smoking cessation in veterans.

And within weeks of enrolling in this trial,

he was having nightmares and flashbacks

and suicidal thoughts.

And this all came to a head one night

when he was confronted by police, while he was apparently

in the midst of a flashback.

At the time, he had a concealed weapon with him,

and this was very serious.

He could have been killed or seriously injured

by the police.

But instead, he was tasered and taken into custody.

And the question is, was the drug

responsible for all of this?

The answer to that question is, we really

have no way of knowing.

The problem is that the drug development

process in the United States is a flawed system.

Right now, pharmaceutical companies

can receive approval for their new drug

on the basis of studies that completely exclude people

with psychiatric disorders.

And then after the drug is approved,

we start seeing cases where someone who is taking the drug

has psychiatric symptoms.

And we really don't have any way of knowing whether it's truly

a drug effect, whether it's nicotine withdrawal,

or whether it's the natural course of that person's

mental health condition.

So we have to make decisions about safety

in the absence of good data.

But we do have more safety data and more efficacy data

coming that's specific to smokers

with psychiatric disorders.

There's been a suggestion that perhaps we

can improve treatment outcomes for particular groups

of smokers by using a targeted approach to pharmacotherapy.

So for example, since bupropion is also

an anti-depressant as well as a smoking cessation drug,

perhaps it could be particularly beneficial

for smokers with depression.

So most research has focused on smokers

with a history of depression.

And the results of those studies have

shown that depression is no more effective than NRT for people

with a history of depression.

Another targeted approach that's been attempted

is extended pharmacotherapy, so going beyond the typical 8

to 12-week course that's recommended as a treatment

period.

Again, this approach hasn't proven

to increase rates substantially, although there have

been some successes reported.

For example, extended NRT for smokers with schizophrenia.

So there's not good evidence about targeted pharmacotherapy

for smokers with mental health conditions.

But what about counseling?

Again, let's start by just reviewing

some general principles of counseling

for tobacco cessation.

The Public Health Service guidelines

give us some guidance on how to deliver

both brief interventions as well as more intensive ones.

The 5 A's approach is a general structure

for a brief intervention.

And the 5 R's are focused on how to work

with smokers who aren't motivated to make

a quit attempt.

On the more intensive treatment side,

the practice guidelines attempt to break down

what's typically a multi-component intervention

into the core ingredients that work.

And the conclusions of that meta-analysis where that

counseling should contain two elements that seem to work--

a practical problem-solving and skills training approach

and intra-treatment social support,

meaning support from a treatment provider or a treatment group.

There have been a few studies focusing

on targeted counseling for subgroups of tobacco users

with mental health conditions.

And these studies have produced rather mixed findings.

Some of the positive trials that showed evidence of success

have been that large study of integrative treatment

for smokers with PTSD, which I mentioned earlier, as well

as some evaluations of mood management

interventions for smokers with depression,

either with or without co-occurring alcohol

dependence.

An interesting finding from these mood management studies

is that the mood management intervention

is more effective than the comparison treatment.

But it doesn't seem to work by reducing depressive symptoms.

And what that suggests to me is that with the right treatment,

smokers can quit even when they are

dealing with current mental health symptoms.

We don't have to make those symptoms go away

in order for them to quit.

There have also been some negative trials

where the targeted treatment didn't

outperform the standard care of smoking cessation intervention.

And I've listed just two examples of that here.

One was a study of integrative treatment

for smokers and treatment for other substance use disorders.

And one was a targeted counseling approach

for smokers with schizophrenia.

So taken together, again, these studies

have produced mixed findings with the possible exception

of mood management interventions for smokers with depression.

However, the findings are based on a small number of studies.

And there have been numerous calls for more research

on this topic.

That includes expert panel reports.

The most recent version of the US Clinical Practice Guidelines

and the US Department of Health and Human Services Strategic

Plan have all called for more research in this area.

There's a lot that we still don't

know about how to best treat smokers

with mental health conditions.

But let me close with some key points about what we do know.

First, we do know that tobacco use

is highly prevalent and extremely harmful

for people with mental health conditions.

This is a critical tobacco-related health

disparities population.

And if we don't do something to change course,

the disparities are only going to get worse.

Second, we can't continue to let our course be guided

by myths, like the belief that smokers with mental health

conditions don't want to quit, or that they can't quit,

or if they do quit, their mental health will deteriorate.

Quitting smoking is one of the best things

that anyone can do for their physical and emotional

well-being.

And having a mental health condition does not change that.

Third, while the data do suggest that it

can be more difficult for people with mental health conditions

to quit, treatment is effective.

And it needs to be provided as often as needed

until the person can quit for good.

Finally, we need more research on targeted treatments

as a way to improve quit rates for people

with mental health conditions.

They do have potential.

But they're not going to be adopted on a widespread basis

without more data on their effectiveness.

If you'd like to learn more about this topic,

here are some great resources that are available online.

Thank you.

For more infomation >> Tobacco Treatment and Mental Health Conditions - Duration: 35:43.

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UNC Hospital School helps sick children keep learning while getting treatment - Duration: 2:26.

For more infomation >> UNC Hospital School helps sick children keep learning while getting treatment - Duration: 2:26.

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Beyond the walls: Pueblo treatment center victim speaks out - Duration: 2:56.

For more infomation >> Beyond the walls: Pueblo treatment center victim speaks out - Duration: 2:56.

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What's Causing Your Abdominal Pain | Abdominal Pain (Causes, Remedies, Treatment). - Duration: 2:18.

abdominal pain causes remedies treatment the abdomen is an anatomical area that

is delimited by the lower margin of the upper ribs the pelvic bone pubic branch

blow in the flanks on each side although abdominal pain may arise from

the tissues of the abdominal wall surrounding the abdominal cavity eg the

skin and abdominal wall muscles the term abdominal pain is usually used to

describe pain coming from organs within the abdominal cavity

for example the skin and muscles these organs include the stomach small

intestine colon liver gallbladder and pancreas occasionally pain may be felt

in the abdomen even if it is arising from organs that are close but not

within the abdominal cavity for example the lower lungs the kidneys and the

uterus or ovaries this last type of pain is called referred pain because the pain

although originating outside the abdomen is being referred to since in the

abdominal area abdominal pain can be acute and suddenly

onset or pain can be chronic and long-standing abdominal pain may be

minor and of great importance or it may reflect a major problem that affects one

of the organs in the abdomen pain characteristics location time duration

etc are important to diagnose their cause persistent abdominal pain should

be evaluated by a physician several causes of abdominal pain include but are

not limited to indigestion after eating gall stones and gallbladder inflammation

cholecystitis pregnancy yes inflammatory bowel disease ulcerative colitis and

Crohn's disease appendicitis ulcers gastritis GERD pancreatitis

gastroenteritis viral or bacterial parasite infection endometriosis kidney

stones Nephila diocese abdominal muscle injury abdominal hernia lactose

intolerance gluten intolerance celiac food poisoning ischemic bowel disease

vasculitis abdominal aneurysm injury of abdomen

organs due to trauma and constipation patient

For more infomation >> What's Causing Your Abdominal Pain | Abdominal Pain (Causes, Remedies, Treatment). - Duration: 2:18.

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Erin Krebs Improving Community Based Treatment - Duration: 20:16.

Thank you. [Applause]

Alright thanks.

So, I routinely fail my eye exams so I have my paper here and it will just be a test how well I know my slides.

So I am kinda making that transition to the chronic side of things.

And, you know, I'm going to start with talking about opioids, not 'cause that's where I want to start, but because that's what has been consuming us, I think, in recent history.

I'm a general internist and a primary care doctor.

And, you know, this is my background slide; this is the place of opioids in primary care.

You know, like, the whole world is sort of revolving around opioids.

Especially when we're talking about pain.

We're talking about addiction.

We're talking about mental health.

Everyone is talking about opioids all the time.

Umm... and so, it didn't have to be this way, but this is the way it is, and this is the way it was when I started to practice.

So, you know, my research has also sort of circled around opioids for better or worse.

Umm

This is my other background slide.

This is the evidence base for long term opioid prescribing as it stood when we started doing this, you know.

This did not-- this did not come down to us as results of multiple randomized, controlled trials showing us that this was an effective way to manage chronic pain, but indeed, you know, primary care was kind of delivered this message that

this is a moral obligation, we have an ethical duty to treat pain, and the effectiveness of this particular strategy was sort of assumed in these messaging-- in the messaging we received.

And just to provide an example of that, this is the first VA/DOD opioid prescribing guideline; a little section from this.

Released in 2003, incidentally the year that I was chief resident at the Minneapolis VA and trying to learn some stuff about pain so I can teach my fellow trainees about how to do it better,

and as you can see here, the recommendation is that opioid therapy is indicated for moderate or severe pain that has failed other interventions.

So if anything else doesn't work, opioids are indicated.

And consider the ethical imperative to relieve pain.

And I don't wanna pick on the drafters of this document, because it's just one of many, but this was the message we were all getting about this is good quality care.

And so sometimes people say to me, how can primary care have done this, and created this mess, and prescribed all these opioids?

Well, we were following guidelines and considering the ethical imperative to treat pain.

And, so, you know.

This is the 2017 guidelines which are a complete 180.

The first statement is "we recommend against initiation of long term opioid therapy for chronic pain."

And, you'll notice in the red box I've just, sort of, highlighted the evidence they cited for that,

primarily, the "rapidly growing understanding of the significant harm of long-term opioid therapy,"

but note still there are no studies evaluating the effectiveness of long-term opioid therapy.

So that did not stop the guideline drafters, from making a strong recommendation, but, you know, that's kind of been consistent with how we do it around opioids;

we have strong opinions and strong recommendations and simply not enough evidence.

Just another example of one of many systematic reviews that have found essentially the same thing, that we just don't have long-term effectiveness data

for this practice that has become so amazingly commonplace that opioid therapy is pretty much the most commonly prescribed treatment for chronic pain these days.

So, I'm gonna tell you a little bit about a trial that I recently completed that some of you know about.

I presented this at the Society of General Internal Medicine meeting in the end of April and no, the paper is not done, it does not impress, so I'm not going to tell you a whole lot.

I will only tell you a subset of the things that I have already publicly presented, but...

I wanted to at least give this to you as a... as a.. as a teaser any way.

So the strategies for prescribing analgesics comparative effectiveness trial was designed to compare benefits and harms of opioid therapy vs. non-opioid medication therapy over 12 months among patients with chronic back and osteoarthritis pain.

Why those two conditions?

Because those are the most common conditions for which long term opioid therapy is prescribed in VA and possibly outside of VA as well.

We chose non-opioid medication therapy as the comparator for opioids because that's-- I thought-- the most practical, common alternative in primary care.

Often what we're doing is deciding whether or not to start opioids or just to keep prescribing other stuff.

Although, there are many other pain treatment alternatives, they're not always as available or directly comparable.

So, we enrolled 240 veterans with chronic back or arthritis pain.

We randomized them in even numbers to opioids or non-opioids.

We followed them for 12 months and assessed their function, their pain, side effects, and many other things.

Our inclusion criteria were fairly straight forward.

They had to have at least moderate to severe chronic pain.

We require that this be the primary pain problem and not the only pain problem, and most these folks had a lot of other problems.

And we excluded people who had absolute contraindications to opioid therapy, so active substance use disorder, cognitive impairment psychosis, current long term chronic opioid therapy.

We did not exclude people with depression, PTSD, and those kinds of things, if they were getting some kind of treatment and weren't actively in crisis or suicidal.

So we randomized them to either opioid therapy or non-opioid therapy.

I should say that what partially makes this presentation, and this study, relevant to this audience is that we embedded this trial within a collaborative care model.

So all the participants in this study got individualize medical-- medication management within their assigned arm.

So the thing that differed between the arms was simply the menu of drugs that they had to choose from, but there was a pharmacist care manager who did the actual treatment for all patients.

They all got follow up visits monthly, and then every one to three months, mostly by telephone, they got treatment to target pain and individual functional goals that were established with that pharmacist at the first visit.

And this really use this telecare collaborative pain management model that I'll just briefly mention.

So this was a study led by Kurt Kroenke, funded by VA, published in JAMA a couple years that tested this telecare collaborative management of chronic pain and primary care.

Primarily -- the key components really symptom monitoring with the PEG, the PHQ-2 for depression, the GAD-2 for anxiety, and then medication optimization.

That's really the same approach that I used in this trial of opioid therapy vs. non-opioid therapy.

And in this trial by Kurt Kroenke, it was an effective intervention with twice as many people responding, 52% who received the intervention vs. 27% in usual care.

So, back to the current study.

All medications in both arms were on the VA formulary.

It changed a little over time and as a pragmatic trial, therefore, there were some changes in what was available.

Each arm had three medications steps.

In general, patients received treatments in each step before moving to the next one.

We limited the opioid daily dose to a hundred morphine equivalent milligrams a day.

And I'll say that, the ground moved so rapidly under the study as we conducted it, that, you know, we were just kind of reeling to keep up with the changes in people's perspectives.

Initially the plan was 200 morphine equivalent milligrams per day and I think we got a little reviewer blow back for that.

That why would you limit that?

But it didn't seem safe not to.

We've lowered it to 100 and we kinda had a soft halt at 60, where if people were not responding, we would really stop and reevaluate as opposed to going up, so not too many people hit the hundred mark.

So these are the drugs we used, and the opioid arm is on the left, the non-opioid arm is on the right.

The first medication at the top with the asterisk on both sides is the preferred initial medication unless we had some reason to start something else first.

So it was morphine IR in the opioid arm, and acetaminophen in the non-opioid arm.

People always ask me about this, because some of these drugs aren't totally evidence-based for chronic pain, but this is how it goes in primary care.

We didn't have a super high bar, but drugs that were used for chronic pain that had at least some evidence of efficacy somewhere, we included in the non-opioid arm.

You'll also notice on the bottom right hand there that tramadol is in the non-opioid arm.

Why? Again, the world changed between 2010 and 2017.

A lot.

Just running briefly through this.

We randomized 240.

All but one received the intervention at 12 months.

All but three in each arm gave us 12 month patient reported outcomes so, we had really excellent follow-up, and we included all but one in each arm in the analysis.

And this is the bottom line.

I'm just giving you the responder analysis, but the main differences tells exactly the same story.

BPI interference, the Brief Pain Interference scale, which is a measure of pain related functional impairment, there was no difference between the arms on that.

About 60% of patients in both arms had a, what we defined as a clinically significant improvement of 30% from baseline to 12 months.

And then BPI severity, our measure of pain intensity.

Umm...

Here the non-opioid arm was superior to the opioid arm, so 41% in the opioid arm had a significant improvement and 54% in the non-opioid arm, and that was statistically significant no matter how you cut it.

I wanted to show this to you.

This is the care management side of things.

You can see we actually did a really good job of giving equal attention to both arms so, on average, 2.8 in-person visits with a pharmacist over a year, six phone visits with a pharmacist over a year, and a grand total of almost 4 hours.

So our summary, opioid therapy was not superior to non-opioid medication therapy, and indeed there was a small significant difference favoring non opioids in pain intensity.

I didn't show you harms, but opioid therapy caused significantly more adverse symptoms.

And, umm...

So in addition to supporting the CDC guidelines that opioids are not preferred, I think it's worth, especially for this audience, pointing it out that we actually had good response rates in both arms.

Right, so...

I attribute that largely to the telecare intervention.

You know, these folks had treat-to-target pain management, which is not normally how we do pharmaceutical therapy for chronic pain.

And if things didn't work, we changed it, in both arms.

So I think that's why a lot of our people did pretty well, even if the individual medications prescribed maybe weren't fantastic.

So, what next? Moving towards the future.

Clearly we have a project in terms of de-implementing ineffective and inappropriate opioid therapy.

There is a lot of that out there.

Umm...

And... the other project really is implementing effective pain therapy.

So, many other interventions have better evidence than opioids do and many of these are pretty seriously underused.

I'll -- just to give you a real brief summary from a VA process that is actually ongoing

VA sponsored a state-of-the-art conference in the past year on non-pharmacological approaches to chronic musculoskeletal pain.

This was actually prompted by the White House, the former President's summit on the prescription opioid crisis and VA at that time committed to focusing on non-opioid therapy alternatives.

So this conference came out of that initiative, and the goal is really to get a group of experts together to look at existing evidence and gaps related to non-pharmacologic approaches for chronic musculoskeletal pain.

We divided that into four categories: psychological and behavioral therapies exercise and movement therapies, manual therapies, and then models for care delivery, most relevant to today.

The goal is to really identify approaches that the VA should consider implementing more broadly.

As well as identifying our research agenda for those approaches that maybe needed more work.

This is one slide summarizing, really, conclusions of the groups about the psychological/behavioral exercise movement and manual therapies categories.

These are the therapies that the conference concluded were ready for implementation on some level in VA, at least basic efficacy evidence being present for these therapies.

The research gaps really related to those same therapies and all the surrounding issues; delivery approaches, dose of therapy, strategies for improving adherence,

engaging patients, maintaining benefits, combining and sequencing therapies, all those kinds of things.

And I'm sure many in the room are not surprised about this.

I mentioned that the fourth category of approaches was this models for pain care delivery.

For this one,...

the group, we did not identify any existing systematic reviews on this topic, which was kinda interesting.

Really for all the other therapy approaches, there was a lot of systematic reviews to pull from.

So what we did was requested an evidence br- brief from the VA Evidence[-based] Synthesis Program and ask them to look at studies

that evaluated models using system based mechanisms to increase the uptake and organization of multimodal in pain care broadly defined.

We looked for interventions that were integrated with primary care, at least primary care adjacent, and specifically not multidisciplinary pain rehab programs done in specialties settings.

And this is just a summary slide from that evidence report, which I believe is available out there online.

The review found eleven articles describing ten different studies.

Umm...

They were mostly randomized, controlled trials of fair to good quality.

They rated 3 of the 10 as poor.

Most of them had 12 month follow-up, in contrast I think often to our pharmaceuticals studies.

Most use the usual care control and most enroll patients who had moderate to severe pain at baseline.

These studies described nine diverse models.

And the puzzle pieces, there are the four, kind of, categories of features that were common to these nine different models.

So, not surprising to anyone to hear that, common features were decision support, care coordination resources, efforts to increase patient knowledge and activation, and then increasing access to multi-modal care.

The review concluded that the best evidence existed for five models, four of which were described in good quality VA trials that combine decision support with case management.

And I think Steve Dobscha is going to talk a little bit more about some of these.

They were the ESCAPE, SEACAP, SCAMP, and SCOPE trials.

And the SCOPE trial is one I already mentioned that did the telecare collaborative management.

They also included the STarT Back trial as one of the study models for which evidence was best.

For these models, they all found a clinically relevant improvement in pain intensity and function.

And the conclusion of the report was really that VA should consider implementation of these models

in a multi-site manner and examine factors associated with successful implementation and effectiveness and practice at the same time.

So I am going to let our additional speakers talk more about challenges.

But this is a key challenge, I think, to moving forward, improving care, and that is that now opioids are basically a black hole for primary care energy, time, and honestly, good will.

You know, I think a lot of people just don't want to hear about pain because they are just sick of dealing with opioids.

And that is a real challenge that as we're doing this, we need to remember opioids are a drain.

What's exciting about treating chronic pain in primary care?

How can it feel good again, you know?

Does anyone ever have success?

Or feel like they did something for a patient and the patient got better.

We do need to-- we need to refind the joy here and escape our black hole.

And then I think this is just meant to represent the obvious structural issues, you know.

Usually it's just one little jump over a hurdle to get access to medication, but, you know, I was trying to get chiropractic treatment for a patient of mine who has low grade chronic back pain, who has an acute flare and that's what looks like, you know.

This huge Olympic hurdles course to try to figure out how you could get something pretty simple done in maybe a few sessions for the occasional patient who needs it.

So, meanwhile, she'd already had three opioid prescriptions, two benzo prescriptions, and two courses of prednisone from the ER.

So, you know, this is a challenge we will continue to face, and I'll let the rest of the speakers talk a little bit more about that.

Thank You.

For more infomation >> Erin Krebs Improving Community Based Treatment - Duration: 20:16.

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Thirty-year-old Eczema : Original Causes, Diagnosis and Treatment - Duration: 3:29.

I understand neither

what on earth the dampness means,

nor the eczema.

I think that the moist weather

and my perspiration result in my feeling.

Every now and then, I hear people say

`The pain can not bring about death,

but itch can`,

if the skin just itches occasionally,

maybe it`s nothing, however,

the itch like old Mr. Sha has

been for 30 years, which can not been relieved

even with various ways,

on the contrary, it become more severe,

you can imagine how

suffering and distressing it is.

Doctor Zhou says old Mr. Sha gets eczema.

Actually, we often hear this name,

but we never consider it carefully.

Do you think what the `damp` mean?

On mentioning the `damp`,

we may firstly think of water,

such as damp clothes

or damp weather,

the `rainy day` in south China

or the `sauna days` is sultry,

sticky and highly humid,

can our body also be ` damp`?

So what on earth does the `dampness`

that Dr. Zhou mentioned mean?

Although old Mr. Zhou did not really understand

`dampness`,

he still went home

with the traditional Chinese medicine

Dr. Zhou prescribed.

I just thought

the traditional Chinese medicine could relieve

my disease thoroughly.

The itch must be relieved first.

Second, it is the dark skin to be relieved.

After getting home,

old Mr. Sha started to take the traditional Chinese medicine,

he soon found he still itched,

but his another disease has been relieved.

My feces used to be dry to evacuate.

It blocked in my anus.

Sometimes, I evacuate the feces every one or two days.

After taking the medicine,

it is evacuated one day one time

or two times,

and thinner, my bowels

has been open from then on.

After his bowel open,

old Mr. Sha felt very well.

After a few days,

he got another surprise.

After I took her traditional Chinese medicine,

I no longer feel itchy for only one week,

my skin became better,

therefore, I feel better than before.

The first time he came with a worried look

and said,`Doctor, you must save me`,

the second time he came with a smile

on his face with relaxation.

He said, Ah, Dr. Zhou,

my itch has been relieved a lot,

now I could sleep very well`.

It seemed that everything was going well,

however, one problem

still plagued Mr. Sha.

At that time, the doctor said,

`You must not eat seafood

such as fish, shrimp,

as well as mutton`.

Among the avoided certain food,

the old man can not avoid one,

i,e, mutton.

For more infomation >> Thirty-year-old Eczema : Original Causes, Diagnosis and Treatment - Duration: 3:29.

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How to Get Rid of Pimples in a Week - Pimples Treatment - Pop Pimples - Clinicyl - Duration: 3:23.

Number 1.

Wash your face twice a day It is very important to keep your face clean

when trying to prevent pimples.

Washing your face removes dirt, impurities and any excess oil that has built

up on the surface of your skin.

Ideally, you should wash your face three a day,

in the morning and noon and in the evening, using warm water and a mild facial cleanser.

Use a clean dry towel to pat your face dry.

Number 2.

Use a noncomedogenic moisturizer After washing it is important to apply a good

moisturizer to hydrate the skin and prevent it

from become dry and irritated.

However, if you suffer from pimples it is important that you use

the right type of moisturizer for your skin type.

Heavy, oily moisturizers can clog your pores and lead to further breakouts.

Look for moisturizers which say "noncomedogenic" on the label --

this means that they should not cause your skin to breakout.

Number 3.

Avoid touching your face or popping pimples.

Hands come into contact with more dirt and bacteria throughout the day than any other

part of the body, which is why you should avoid touching

your face at all costs.

In addition to spreading bacteria and risking infection, touching spots

and pimples can cause them to become irritated and

inflamed, thus worsening their appearance and prolonging healing time.

Number 4.

Use exfoliating treatments and face masks once a week

Skin exfoliators and face masks are great products which can be very beneficial for

the skin, but they should only be used sparingly.

Exfoliators remove dead skin cells while effectively cleansing the skin, but can be dry out and

irritate the skin if used to often, especially on pimple-prone skin.

Number 5.

Avoid overloading your skin with products.

Too many creams, lotions and gels can clog your pores and lead to breakouts,

so make sure to apply any facial products sparingly, and no more frequently

than is indicated on the packaging.

The same goes for make-up, which should be applied as lightly as possible and should

be thoroughly removed using a facial cleanser at the end of each day.

Number 6.

Protect your skin from the sun.

Although traditional advice encouraged the exposure of pimple-prone skin to the sun,

with the belief that this would dry pimples out, modern-day skin specialists say otherwise.

The sun's UV rays can actually cause pimples to become even more red and inflamed than

before.

Number 7.

Eat well Although it's been proven that chocolate and

other junk food don't actually cause pimples, staying away from oily, greasy foods can still

have a positive effect for your skin.

Pimples form when excess oil clogs up your pores, so limiting the amount of oil that

you put into your body in the first place is a step

in the right direction.

Plus, if your body is healthy on the inside, that will be reflected

on the outside.

Number 8.

Drink plenty of water.

Drinking water has many benefits, for the skin and for the body's overall health.

It keeps the body hydrated, helping skin to look firm and plump.

It flushes harmful toxins from the system, preventing them from building

up and causing skin problems.

In addition, water helps ensure the proper function of

the skin's metabolism and allows it to regenerate itself.

You should aim to drink 5 to 8 glasses of water a day to reap the benefits.

For more infomation >> How to Get Rid of Pimples in a Week - Pimples Treatment - Pop Pimples - Clinicyl - Duration: 3:23.

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Invented Arizona, Episode #4: "Prevention & Treatment of Clostridium difficile Infection" - Duration: 10:12.

Hi welcome to Invented Arizona! I'm Paul Tumarkin and I'm Taylor Hudson.

We are with Tech Launch Arizona, the office of the University of Arizona that

commercializes inventions stemming from research.

In this edition of our podcast we're talking with Gayatri Vedantam. She's a professor in the School of Animal and

Comparative Biomedical Sciences in the UA College of Agriculture and Life Sciences.

She and her co-inventor, 'Vish' Viswanathan have developed a new technology for preventing and treating the

Clostridium difficile or C.diff bacterial infection in the gut.

So Gayatri, let's start with what the C.diff bacteria is for those who don't know.

So Clostridium difficile is an enteric pathogen. That means it's an organism that causes disease in the

gastrointestinal tract and it is a gram positive bacteria and an organism that forms spores.

And so when Clostridium difficile is exposed to any sort of

harsh condition it changes into this very hearty inert structure that can

survive for a very very long time on surfaces. And it's a real problem because

it's ubiquitously present everywhere in the environment including in our

hospitals and our communities.

All right so it takes a certain kind of condition for someone to get an infection like this.

What things do we do that create these kinds of conditions where the bacteria can grow?

Okay that's a great question.

So Clostridium difficile infection, or CDI, is caused when the normal microbiota,

or the good bacteria, the good microflora in our intestinal

tract is depleted or suppressed.

And most commonly this happens upon antibiotic treatment.

So many many humans and animals will get antibiotics either prophylactically or preventively or therapeutically or for treatment.

And one inadvertent byproduct of that antibiotic treatment is that all of our good

flora are suppressed. And when good bacteria are suppressed in the GI tract that

means that niches become available for pathogens like Clostridium difficile to

now enter and colonize.

And like I said previously, this is a pathogen that's

present ubiquitously in the environment so contact with surfaces which contain

the spores or even any kind of object in the hospital or in the community that

has those spores result in Clostridium difficile entering the GI tract and

essentially colonizing the vacant landscape that's now available because

of antibiotic suppression.

It effects about up to a million people in the United States and if it's not diagnosed quickly enough,

and not treated properly enough, it is also associated with about 30,000 fatalities.

What type of symptoms will someone with a C.diff infection experience?

So once the organism gets into the intestine and establishes a foothold,

it might produce up to three different toxins or molecules that cause diarrhea

and so the disease is actually a diarrheal disease and it's very difficult

to treat because the treatment is more antibiotics and obviously continued use

of antibiotics further suppresses the microbiota so it's an ironic offshoot of

modern medicine.

Wait so this sounds like kind of a vicious cycle!

You're treating something that antibiotics caused with antibiotics.

So for your technology are we talking about prevention or a treatment?

Well we hope it will do both.

So the goal of the research in our laboratory is to try to ultimately look

for interventions to prevent or treat C.difficile infection without the use of

antibiotics and this technology that we have right now is based on something

that I said earlier, which is all this vacant landscape that opens up

after antibiotic treatment and our technology is based on the premise that

if we can colonize that landscape with good bacteria that occupy the same

niches that C.diff would occupy, we can prevent the establishment of any

C.difficile spores that get into the GI tract and then settle in or find a home.

So our technology actually uses genetic engineering to manipulate good and safe

bacteria to express proteins that C.difficile would normally express on its

surface and use to colonize the GI tract. So we are pre colonizing the GI tract

with our agent and that essentially is designed to prevent further occupancy by

Clostridium difficile. That would be a preventive and there's the scientific

basis of this project is that if we can prevent colonization of Clostridium difficile

then we don't have to worry about the downstream impacts of the disease.

The organism is only going to produce toxin very late in its growth

and cause all of the problems that it does if it's allowed to linger and if we

prevent the establishment in the first place we won't have to worry about

lingering organisms.

The hope is that we can also use this technology to knock

any existing C.difficile organisms "off their perch", so to speak.

That would be a therapeutic option and we're developing that right now.

So we know there are different strains of C.difficile - will your technology be

applicable to variations in the bacteria?

So I'm really glad you're asking that question, that's actually an outstanding question.

One of the big worries or the concerns in the C.difficile research area is that this organism exhibits

incredible genetic diversity. So we use something called a molecular typing

method to classify C.difficile into all the different flavors of which strains

are some of those flavors.

And right now there's over 500 and ribotypes, or molecular types, of Clostridium difficile,

many many many of which, if not all of which, are circulating in North America.

And our surveillance in Tucson says we have many different flavors in our Tucson area hospitals,

so our technology was specifically engineered to be widely

applicable and prevent infection caused by multiple different C.difficile strains

So when we did our preliminary studies we actually tested it on all the

circulating strains of Clostridium difficile in the Southern Arizona area,

and those studies are obviously continuing, but you're right,

our technology really is not going to be very useful if it doesn't prevent

disease caused by all the different flavors of C.difficile so it is

engineered to do exactly that.

Once it's available to the public how will we be able to take it?

The dosing of the technology is actually going to be based

on safety so right now the way that we've designed it is that our technology

will not actually stay in the GI tract very long and further disrupt any of the

microbiota that are trying to come back.

So we actually see this technology as a "use it when you need it" or "use it just before you need it" type of technology.

It will require once daily dosing at this point but in our laboratory studies as

few as one single dose of the technology is enough to actually prevent the

disease of the organism.

But the recommendation is going to be that we take it once a day.

It will be less than half a teaspoonful of a yogurt-like formulation.

Well that sounds easy enough! Thanks Gayatri so much for coming on the podcast

and sharing your technology with us today.

I would like to say a huge

gigantic shout out to the people that work in our laboratory.

None of this happens without the incredible effort that the whole team puts together

and I don't think we could ask for a better more dedicated team.

We also have veterans in our laboratory that for whom this disease is a huge problem

and so we have students that actually served in Iraq and Afghanistan,

finished their tour of duty and came back and are working in the laboratory to solve this problem

that many of their members of their community are facing or have faced.

And I think it's it's an incredible testimony to their hard work and effort that our

technology is getting off the ground.

So I would like to acknowledge them and all of our collaborators here at the U of A.

And our hospitals here in Tucson.

Wow Taylor, that was a great conversation!

Thanks for getting us some time to talk with Gayatri.

And thanks to all of you for listening to Invented Arizona!

For more information about this invention and all the other great inventors and inventions from the

University of Arizona, visit Tech Launch Arizona on the web at

techlaunch.arizona.edu

We are @TechLaunchAZ on Twitter and you can also find us on Facebook and LinkedIn.

And as always please subscribe to our monthly newsletter for stories,

updates and events from around the University of Arizona ecosystem.

You can find that at bit.ly/TLASubscribe.

Thanks for listening!

For more infomation >> Invented Arizona, Episode #4: "Prevention & Treatment of Clostridium difficile Infection" - Duration: 10:12.

-------------------------------------------

Addressing Disparities in Tobacco Dependence Treatment - Duration: 48:10.

TIM MCAFEE: I'm Tim McAfee.

I'm sure that Abigail has already introduced me.

And I just want to emphasize how excited I

am to have this opportunity to talk with you

remotely for a few minutes about a topic that's

near and dear to my heart, addressing disparities

in tobacco dependence treatment, an area

that I've been working on literally for probably

10 or 15 years in many different capacities,

from being a primary care physician to being a tobacco

treatment direct provider of care to overseeing services

in the quit line arena in Seattle,

both within Group Health Cooperative

but also within a private company that provided services

to states and employers and health systems.

And then for the last five years working for CDC in Atlanta.

And now out here in the Pacific Northwest,

and where part of my role has been

to try to improve the interface between tobacco treatment,

to increase its dissemination and uptick

and quality with other tobacco control activities.

So without further ado, what I hope to cover is first,

I'm going to talk a little bit just

to make sure we're on the same page around what we

mean by the word treatment.

And then I'm going to talk about tobacco users themselves

as a total population, being a population that suffers

from health care disparities.

And then we'll look at some of the specifics of priority

populations of tobacco users and how

they may suffer from health and health care

related disparities.

And then I'm actually going to spend some time, fortunately,

talking about some of the solutions

that we already know can work in this arena and others

that have promise.

And now I'm now on slide number three.

And I'll try to give examples of when I'm switching.

So when we say treatment what are we talking about?

Well, if we take the larger universe of all people,

within that, there's a subgroup of about 15% to 20%,

depending on how you define it, or larger, if you're poor,

et cetera, who are using tobacco products.

And within that subgroup, there's

a subgroup who are actively trying to make a quit attempt.

And at any time, that's going to be something like 10% to 20%.

Over a year, about 50% of people try to make a quick attempt.

Within that subset, there's a smaller subset

of people who actually use evidence-based treatment

to try to get help.

And within that subgroup, there's

the smallest group, which is those

that use sort of the full meal deal, that

take full advantage of all that we know potentially can work.

We'll talk more about this.

But it's important from a public health perspective

to keep in mind that if we only define treatment as hey,

can we make better that tiny little group of smokers

that are going to the Mayo Clinic for treatment

and getting hospitalized to be treated for their tobacco

dependence or whatever?

That we are going to be ending up

talking about a tiny, tiny, tiny fraction of smokers

that is essentially meaningless from actually impacting

the prevalence of tobacco use.

So we have to realize that all these different circles are

kind of permeable.

And people, whether they move between them or not,

depends on things that we do in society.

So for my next slide, I'm going to essentially take

the next phase of this, which is you take those circles

and look at them.

It's important to realize that the things that we might

be able to do to increase these, which I'm going to talk about

next, interact with each other.

And some of them only work in one circle, like having--

creating-- going from using nicotine replacement therapy

patches to using one of the higher

efficacy things like Varenicline,

will only work in the circle on the right.

And it won't necessarily affect how many people

are likely to make a quit attempt

or whether they're going to try to use anything at all.

But there are some things that may work on all three.

So what do we know that works for treatment in general?

We know that we can increase the likelihood that people

will make quit attempts through comprehensive clinic system

interventions.

This is called the 5-A model.

I don't know if you've been exposed to this,

but this basically means that we set up

clinic systems that encourage or require

health care providers to determine what people's tobacco

status is at almost every visit, that they give

brief advice, that they help provide a little assistance,

and that they try to connect them up with resources

to support them and make sure that they get follow up.

And that will affect all three of these potentially,

has the possibility.

Mass media campaigns definitely are

well-proven to increase quit attempts in the population.

I'll be talking more about that as a case example later.

We also know that state and local comprehensive tobacco

control programs, everything from [INAUDIBLE] to tax

increases to community mobilization,

will work to make more people in that geographic area

try to quit smoking.

For the second, for increasing use of evidence-based support,

first, what are we talking about here?

This is predominantly conceived of as medications,

seven FDA-approved medications, and counseling,

which can be provided in multiple locations

and multiple modalities.

Lots of evidence that these work.

The big issue is how do we actually

get people to be aware that these exist

and remove barriers to them actually

being interested in using them and then actually using them?

And finally, how do we increase the effectiveness

of the support and treatment for people who are saying,

yeah, I'd like to do something?

And there's a couple of fairly straightforward ways

to do this.

And these include the combining modalities,

so people don't just use medications.

They also use counseling, and vice versa.

It also can mean that they use multiple medications.

Now, the other one is to essentially increase

the dose and duration and instruction

that people get on how to use these different modalities,

whether that's counseling or whether that's medication.

All of these things definitely have

been shown to increase the effectiveness of support

and treatment for people that are interested in getting it.

I want to now toss out something that--

I don't know if this has come up in any of your previous talks

that you've had.

But I just want to throw out the idea, based

on my long experience working with smokers and systems,

et cetera, that people with tobacco dependence

experience health care disparity compared

to non-tobacco dependent people.

So before we go into subpopulations

of tobacco users, I think it's very important

to realize that tobacco users as a category,

as a subpopulation of all of us, experience health care related

especially disparities.

And I'm just going to talk about a few of those.

The first is that tobacco treatment research

historically, over the last 20, 30 years, although there's

been a lot of it and we've made a lot of progress,

it has not been prioritized in an urgent sense

consistently, the way many other forms of treatment development

have been in kind of traditional medical care.

We have seven medications that work.

But the reality is five of them are just

variations on nicotine.

And one of them is an anti-depressant

that's been repurposed.

And the other one is actually a variant on an old Eastern

European herbal medication.

So there has not been the kind of aggressive attention

to pharmaceutical development that there

has been in, say, chemotherapies,

antibiotic development, et cetera.

And the same is true with counseling modalities as well.

But we do have things that work.

And of those, it's been incredibly frustrating

over the last 20 plus years, the efforts

that it has taken to get these exquisitely proven modalities

that work to be covered.

And if covered, to then be integrated into health care

and health care systems.

Now, the other thing that is worthy of note

is that users of this exquisitely addictive product

are taxed heavily on the product.

It varying widely from state to state,

and certainly a state like Washington,

there's a pretty strong tax as well as

master settlement revenue that's coming to the state.

Almost a billion dollars comes into the coffers

for the state of Washington from the sale of tobacco products.

But the revenue that the state generates,

or the federal government, and in some cases municipality

generates is not applied to treatment or prevention

of tobacco.

So we're taking the money out of the pockets of the smokers,

hoping that the fact that they have to pay a little more

will help them be a little more motivated to quit,

but we are not in general using that money

to provide treatment.

Now, under the Affordable Care Act,

tobacco users also now are one of the only groups in which

insurers are allowed, if the state allows insurers,

they have it.

But they have the authority and OK from the federal government,

that if they want to, they can charge significantly higher

premiums, as much as 50% higher, to somebody based solely

on tobacco status.

They can't do that if you're diabetic.

They can't do that if you're an alcoholic.

They can't do that if you really have almost any other kind

of medical condition.

Now, there's reasons for that.

But it creates a health care disparity.

And then finally, as I'm going to go into an a little bit

more detail, the environment that smokers are facing right

now has been designed historically

in collusion between the tobacco industry, government,

and other parts of society over the last 100 years

to really support addiction and make it harder to quit.

So bottom line is, if you're a smoker, the money that you're

spending to purchase the product that you're addicted

to is going to be used to help pay for other people's health

care, as well as potholes and roads, et cetera, whatever

the state decides it wants to, through taxes

through the tobacco master settlement.

However, despite this, you may be denied coverage, awareness,

and access to well proven treatments that

could quadruple your chances of success

if you use them full bore.

And in addition, you may have to pay significantly more

for your health care solely because you're

a smoker, while your next door neighbor with diabetes,

alcoholism, or obesity does not.

And finally, you continue to be exposed

to almost unfettered marketing and access

to a deadly, highly addictive product.

So this is really an unusual situation and one

where I think it's very important,

as we drill down on subpopulations of smokers,

to not forget that smokers as a group

are suffering from health care disparities.

Now, just a little bit more on the environment larger.

This is not just looking at treatment.

But it affects treatment, because it

affects the ability of a health care provider

and a patient being treated to be able to be successful.

So what's the situation been historically?

And this has been changing.

But this is what we face certainly up until 10,

15 years ago.

Tobacco is remarkably easily accessible.

You can literally buy it at something that's

called a convenience store.

It's convenient to get it.

It's also accessible because the price has

been historically quite low.

And in many states it still is quite low.

Smoking in public up until 15 years ago

in most of the United States was legal,

making it much harder for people to quit, because they

are exposed to nicotine as well as being

likely to have the reinforcers.

There's unfettered advertising.

Go back 50 years, and there is advertising on television.

Go to 2015, and now there is again

advertising on television for some tobacco products.

There was poor to no access to cessation help.

The first medications were not even approved until the 1990s.

And then finally, the cigarette itself as a product

is exquisitely designed still, despite having

been under FDA authorities, still exquisitely designed

to addict, which makes it harder for smokers,

when they're trying to quit, to be able to quit.

Now, I just want to emphasize a couple of points

that I've made around here with a few specific facts.

The first is, one of the things that we call for around this

is the fully funding of comprehensive, statewide

tobacco control programs.

And by the way, we're now on slide nine,

in case there's been any trouble following this.

So this is a graph that shows what's

happening in terms of money that's coming in.

The states get $25 billion, as you

can see in the left, of tobacco tax revenue.

The federal government gets $15 billion.

So the government is getting $40 billion, $40 billion dollars,

from the sale of tobacco products, which

is a little bit more than the global profits from tobacco

sales.

Now, the tobacco industry is still

spending almost $9 billion on marketing promotion.

CDC recommends that a little over $3 billion

should be spent by government on tobacco control

activities writ large.

The reality is state tobacco programs

are only spending about half a billion dollars.

And funding is perpetually at risk.

Even the money that's being spent by the Centers

for Disease Control on tobacco, for instance,

is under threat literally this week,

being threatened with having its budget cut in half.

I'll mention this a little bit more when we talk about some

of the solutions that are under way.

So we as a society are now collecting $40 billion

from smokers, but spending less than 2% of that on anything.

And that does not--

that's including everything.

So treatment is only a small fraction of that.

Now, so what has been done over the past few decades

to try to do something about this conundrum, this disparity,

this social justice issue?

Up until relatively recent times,

mostly what had been done is what I would call jury rigged

solutions.

It was people trying to figure out

ways to get smokers help realizing that they don't have

what they should have, which is that this was just

embedded and worked into health care financing and health care

delivery.

So for instance, we had initially we

had NGO groups, maybe philanthropic hospital

organizations, the Cancer Society,

the Lung Association creating little groups that worked well.

They were in the inner circle that I showed you earlier,

something that was effective.

But a tiny, tiny, tiny fraction of smokers used them.

They either had to be paid for by the individual,

or the NGO, the non-governmental organization,

had to support the costs.

We then developed in the 1990s state sponsored

quit lines that really mostly existed outside of health care

and were paid for by the state government,

not by health care system financing.

And then, within the health care systems themselves,

it was basically left to health care providers and clinic

managers, et cetera to sort of decide

what they were going to do or get research dollars to support

any efforts that they made to help smokers,

because it was not reimbursed.

If you talked with a smoker to try to help him quit,

it was just off your hide.

You couldn't bill for it up until remarkably recently.

The other thing that then happened

after this was the development of these more systematic

approaches to try to integrate treatment into care.

We had the 5-A health system approach that I talked with.

We said we started having quality improvement

and assurance indicators of providers who

were providing services.

And we saw improvements and changes

in health care treatment for the easy things

like checking in on status or giving brief advice.

But there are still major gaps around making sure

that people get medications, people

get counseling if they want it, and that they get systematic

follow up.

We still have significant way to go on that.

The other thing that we have seen,

which has been very exciting, in the last three or four years

has been mandates, essentially, within the Affordable Care

Act that have--

and that CMS, Medicare and Medicaid

are requiring for health care systems and providers

to provide smoking cessation.

But this is still very early, and there's

a long way to go before it's clear

that this is going to happen.

So again, smokers as a class are experiencing health disparity

around this condition that takes 10, 11, 12 years just

on average off their life expectancy.

They can't get the kind of treatment

for their smoking dependence that they

could get for other health care conditions.

And lastly, we've been working, and I'll talk more about this,

to integrate media campaigns that

are happening at the national level with a call

to try to help link people up with evidence-based care.

Now, so in summary, where are we trying to get to?

And where we're trying to get to is to make it so,

for the individual, their tobacco addiction

can roll downhill, instead of the earlier slide

that I showed where they had to push it uphill.

So tobacco is more expensive, so they have to think twice

before buying it.

It's less accessible.

There are thorough smoke-free policies, ubiquitous,

which you may not realize being in Washington state,

there's still a large number of communities

where you can still smoke in a restaurant, et cetera.

You may even be able to smoke at work.

Where there are well-financed counter marketing campaigns

and promotion restrictions with teeth.

And of course, which is what we're going to focus on,

continue to focus on, is easy, reliable access

to help quitting, to treatment for those who want it.

And then lastly, that cigarettes are made less or non addictive,

which is essentially something that only the Food and Drug

Administration can do.

Now again, the Surgeon General in 2014

called specifically that we needed

to fulfill the opportunity that the Affordable Care

Act provides of access to barrier free proven tobacco use

treatment.

And this includes both the seven approved cessation medications,

of which five are variants on nicotine replacement

therapy, bupropion, which is also an antidepressant,

and Veranicline, which is a variant on cytosine, which

was a Eastern European herbal medication that

helps people quit.

And then we have the association counseling delivered

both in multiple modalities, whether that's

in one on one face to face sessions,

whether that's delivered over the telephone,

or whether that's delivered in group,

and increasingly, even potential other modalities

like web and text support delivered

by potential multiple different kind of practitioners.

Now, next I'm going to talk about where

that happens that we know there's evidence

that if you do this, it works.

And again, there's a lot that we know about the system

stuff around this.

It's more a question of application.

We need to expand cessation, primary and speciality

care, with health system support, health care provider

training, in-person counseling, medication availability,

quit lines, web and text, and affordable coverage act,

as I've talked about.

OK, so that's for smokers writ large.

But there are some really, really significant disparities

and social justice issues around treatment

specifically in priority tobacco control populations

or subpopulations.

And many of these patients that you've been learning about,

the treatment applies to them as well.

There are a few others which again, I

don't know if you've talked about,

but that also are becoming more significant around treatment.

And I'll just start off with some

of the ones you might be less likely to think about.

One is geography that, particularly as

in the south and the lower Midwest, the states that

did not opt in for Medicaid expansion and are, in general,

have a far larger uninsured population.

All those people are sort of out of luck

if they want to get help quitting smoking.

And many of those are states that

also have less in the way of state

supported resources, like quit line support.

And another variant on this is rural access,

which can be true all across the country.

And then there's a large bucket, which

I will talk about more, around mental health, substance abuse

and chronic diseases.

And for all three of these categories,

there have been enormous, enormous biases

built in to the systems that have made it much, much harder

for people that have schizophrenia, that

have manic depression, that are suffering

from serious depression or anxiety.

It's even harder for them to get treatment

or to be in an environment while they're

getting health care treatment that

is supportive for quitting.

There is strong historical-- it's probably

the mental health and substance abuses is the worse.

But this is true even within diabetes, HIV treatment, et

cetera.

Now, the other one that is incredibly important

is low SES.

And I'm going to talk about that more,

and I'll also talk a little more specifically

about racial and ethnic.

So I'm going to go on to that.

So socioeconomic status influences a person's ability

to access and receive health care,

including their ability to access help quitting.

So we know that quantitatively, low SES smokers

are less likely to receive cessation assistance

from a health care provider, and that the cost

and lack of coverage is a barrier to cessation treatment.

It's harder for people with low SES to access resources,

especially if they require things like payment,

but also time away from family, arranging

transportation, et cetera.

There's also a little bit more of a generic distrust

in the medical establishment.

And particularly smokers may be less likely even to be seen.

And I do want to mention--

I'm going to get to solutions.

And I will mention that many of these

are-- we have determined-- for instance,

I'll just say from my own experience

around quit lines that being less likely to receive

assistance, if you remove the cost barrier and the access

barriers by making it incredibly easy for somebody

to get access, then you do get people who are low income.

They do use the services, and they do benefit from them.

So this is not something that, again, has to stay this way.

It's just the way it historically has been.

Now, excuse me, the other thing just on SES--

and by the way, I'm on slide 15.

Now, the environment is more tobacco user friendly.

We know that convenience stores that

sell tobacco are at a higher density in low SES communities,

which just makes it harder for people to quit and stay quit.

There's also evidence even around things

like secondhand smoke that low SES communities may have more

exposure to secondhand smoke.

OK, going on to slide 16.

Just to talk a little bit about race, ethnicity, specifically.

Just a couple of things that we do know.

I'm kind of using African-Americans as an example

here.

We know, interestingly, going back to the very first slide,

I showed you about quit attempts and success, et cetera,

Africa-Americans have a higher baseline

quit attempt rate than the general population of smokers,

which is good.

But they have a lower quit success rate.

And interestingly, those two kind of almost, you know,

they cancel each other out so that their overall rate

of quitting over a year is similar to whites,

for instance.

But we know that they also have a lower utilization--

and I've had some articles that some of you

may have read that talked about their lower

utilization of some health care associated

treatments, particularly medication use and longer term

medication use.

However, the other thing that we know

is that they do use treatment.

They have similar success rates to other smokers.

And just to give one specific example that

has been very well researched, almost counterintuitively, what

we found-- the California Smokers Help Line help

us found this.

And this actually was found in Washington and Alaska

and Oregon as well, that African-Americans actually use

quit lines at a higher rate, even without there being a--

the campaign itself not being targeted to African-Americans

or the promotion of the quit line

not being targeted to African Americans.

So there's a lot of potential there.

I'll talk about a specific example in a little.

Now, I wanted to give another example of a chronic disease

where smoking historically has been--

there's a health disparity within a health disparity.

And this is within really the HIV community,

for which the LGBT community disproportionately suffers,

particularly gay men.

And this slide, just to convince you of how dramatic this is,

this is slide 17, a graph.

If you look at this, if you're in--

the bottom line on the right, which shows HIV and smoker,

is a mortality, all cause mortality

curve as people age done from following

13,000 people in Denmark.

And essentially what they found is, if you are HIV

and you are a smoker, you are going to die a whole lot--

at a much higher rate than if you--

you're going to lose over a decade of additional life

beyond just having HIV or beyond just having smoker.

That HIV alone and smoker alone have actually similar effects

on mortality.

This is true now because we have treatments for HIV that

have turned it into a chronic disease instead of a death

sentence.

But it now means, and this is what

HIV experts around the country and the world

are beginning to grasp and try to figure out

what to do about, it means that the single strongest most

powerful intervention can be done in people that are

in good HIV care settings are getting antiretroviral therapy

et cetera, the single strongest most powerful thing

that they can do if they smoke is to quit.

And as this slide illustrates, they

smoke at 2 and 1/2 times the rate of the general population

despite this fact.

So there is something around a health care disparity

associated with smoking that cannot and must not be ignored,

because it is causing a markedly higher death rate in almost

half the people that have HIV.

But yet historically, this as a risk factor

has been almost ignored.

Now, OK, I'm going to talk about solutions now.

I'm going to close up with some solutions.

What can we do about this?

Why haven't we done more?

Well, here's an awesome example.

About a decade ago, we had Romneycare. in Massachusetts.

Didn't call it that now, but let's call it Romneycare,

where we essentially had the precursor to the Affordable

Care Act.

And as part of this, when this was rolled out

there was a general smoking cessation benefit

that covered multiple modalities of counseling and medications.

There was a very strong promotion

and systems in place in Massachusetts

that were unusual for making it easy for people

to access them for help quitting.

And when they did this, 37% of Medicaid recipients

over a very short period of time, just a few years,

used the benefit.

And this is tenfold more than what we see

under ordinary circumstances.

It was amazing.

And among the Medicaid users in Massachusetts,

the prevalence of smoking fell from 38% to 28%

in just a couple of years after this happening.

And in the next few years, they saw a 50% reduction

in cardiovascular hospitalizations.

So basically, what this showed was that insurance based

coverage in smoking cessation treatment,

especially with strong promotion and access,

increased quit attempts, the use of treatments,

and successful cessation.

So you would think, 10 years later,

that all 50 states would have set something up

like Massachusetts.

That has not happened.

That's a more complicated question.

But certainly Massachusetts showed

that it could be done at the state level.

Now, here's again another system.

The Veterans Administration has been doing a lot of work

over the last 20 plus years trying to figure out

what to do about veterans who have

a significantly higher rate of smoking

than the general population.

So they did a trial where, rather than just

try to fiddle with what to do with veterans

that came in for care, they actually had an outreach

where they--

and this is a randomized trial, where half the people got

usual care, the half the people who

got an offer of telephone or in person cessation

services via mail and proactive phone recruitment that

was very carefully executed.

They followed them up all the way to a year

and found 13.5% abstinence, which was statistically

significant compared to 10.9%.

When they started adjusting for things,

the effect size got actually larger.

And that may sound like not very much.

But if you're getting a couple percentage points

more of people quitting every year,

that is a very, very powerful population-based intervention.

This was measuring a population effect, not just those

who took part in treatment.

It was everybody in the population

was part of the denominator.

Now, I'm going to close.

There are multiple other things like that.

And I gave you some reading for some of those other things that

have been done kind of along those lines, ways in which we

can proactively outreach to smokers

in a defined population, rather than

just sitting back and hoping that they'll come in.

I'm going to close just talking a little bit

about the thing I've had the most experience

about over the last four or five years around this issue, which

is the Tips From Former Smokers' national mass media campaign.

So just I'm going to give you a little background about that.

And then I'm going to focus in on why am I telling you

about this since I think you heard from Cheryl Healton

previously about mass media campaigns.

What's the tie in?

Well, the tie in is it provides a golden opportunity

to also do stuff around treatment, access,

and awareness issues.

So this is a large national media campaign

that has been run by CDC over the last four years, first time

in 50 years that the federal government ran

a large national funded media campaign.

Its goals were to raise the awareness of negative health

effects caused by smoking, to encourage smokers to quit,

and to let people know that free help is available

b calling 1-800-QUITNOW.

And so a lot of work went into that last third bullet

to make sure that it could really happen.

It was no mean feat getting that to occur.

Now, in terms of the issue of subpopulation, social justice,

health equity, health care issues,

the Tips campaign targeted this pretty long list

of targeted populations.

And I would just add that, in addition to the large bullet

ones, upcoming there are three other groups that

were added to this.

One of them is essentially e-cigarette users

who are continuing to dual use, because we see them

as a very high risk, somewhat akin to what happened 30,

40 years ago with filtered cigarettes,

that if people think that dual use is

a solution to their problem, using both e-cigarettes

and cigarettes, the will probably be very sorry in five,

10, 20 years.

But we also are focusing more on mental illness.

And this has to do with some results I'll show you.

And there's also some specific work

being done with the military, as with the VA,

in terms of higher smoking rates in that subpopulation.

So one of the things is the ad campaign was developed.

There was a very strong commitment

to showing the diversity of US smokers.

However-- so there was a higher proportion

of African-Americans, Native Americans,

Hispanics than actually is their prevalence within the smoking

population, just to name a few.

We also-- we're sure to do some LGBT ads explicit.

These are just a few of these ads.

But the interesting thing in our findings,

and that have been true in other findings as well,

is that it did not seem that the race or ethnicity of the ad

participants affected the receptivity of the people that

saw the ads.

If you were white, you were still equally moved

by seeing an African-American, say Julia in the ad

that you see here.

By the way, we're on slide 22.

You're equally moved by seeing her as you would

by seeing somebody that had the same skin color that you had.

So we didn't try to literally make sure

that African-Americans saw African-American ads,

whites saw white ads, LGBT people saw

LGBT ads, et cetera, et cetera.

There was some effort along those lines.

But we didn't worry about it too much because of this evidence

that people can empathize with other human beings

regardless of the color of their skin.

I'm just giving you this to also say, however, that we tried

to look at people from the--

we most surely tried to use people

from the target populations that have a specific experience.

This also shows our recent effort

to try to mobilize both people with HIV

but also the practitioner community

to be more aware of the fact of the important role

that smoking plays in increasing people's life

expectancy if they have HIV.

We did a lot of work that was specific

to specific subpopulations that might have particular barriers.

And this slide actually illustrates the one

that, in many ways, I think the most important,

is language and cultural relevance.

So even though, if you look at the slide-- and again,

this is slide 24.

If you look at the one on the left,

you'll notice that the three ad participants [INAUDIBLE]

not Asian.

But it is in an Asian language, and the 1-800-QUITNOW number

at the bottom is not 1-800-QUITNOW.

It's a different number run by the California Smokers Help

Line, although the ads were done throughout

some major metropolitan areas in the US

with special Asian language help lines to help people.

And on the right side of the slide,

you see a shot from some of the shows that

were done on TV in conjunction with this that

have to do with the Spanish lines,

that people who speak Spanish could call a Spanish line.

So that is probably the most important way

in which clearly, the treatment needs to be tailored.

If you can't provide language appropriate treatment,

everything else is kind of irrelevant.

Now, I'm not going to go into detail around this.

This just basically shows there was a lot of work

also to make sure that these different subpopulations

actually were able to see the ads.

And if you look at the reach, you'll

see that it was between 70% and 90%

in all these target populations.

And the Spanish one is probably an underestimate,

because it does not include the Spanish speaking--

the ads were done specifically in Spanish speaking media.

We also developed a lot of active partnerships

with community organizations.

A lot of these are in treatment communities

related to specific medical conditions

like colostomies, retinal, macular degeneration,

the cancer treatment centers, on and on,

with the different conditions that were highlighted

in the Tips campaign.

And we tried to work to not just have this be about oh, the ads,

but also as an opportunity to talk with them about how they

could increase treatment access for the people

that they served.

This just shows that awareness was

high in the subpopulations for the various conditions

across ages, across gender, across race,

and that in some of them, again, they

tended to be higher in the ones that we were targeting.

Now, I also just want to mention that the receptivity of the ads

actually tended to be higher in African-Americans

and Hispanics, that they thought the ads were convincing,

attention grabbing, and powerful,

and had stronger reactions.

Now, honing in now on the question

of how we use this to improve treatment access.

Every ad at the end was tagged "You can quit.

For free help, call 1-800-QUITNOW."

Or a web site was given for some of the ads,

particularly later at night.

And this slide, slide number 29, just

shows basically how, in all four years of the campaign,

the tag in the ad resulted in something like a doubling

of calls to quit lines.

And we worked hard to make sure that people

that called the quit lines would get brief counseling,

encourage them to get medication.

We're actually going to do more work in 2016

after doing a pilot last year that would actually

advertise the fact that people may be able to get--

improve their access to nicotine replacement therapy

by calling a quit line.

So we're trying to make sure that people feel like they can

get easy access to evidence-based treatment

and to improve the quality of the infrastructure,

to actually be able to deliver on our promise, which

is no mean feat.

This year we're also going to be trying to work more

to try to get the state sponsored quit lines to work

more closely with the health care systems that

should be footing the bill for some of this.

This just shows you, we saw the same thing

when we had a week where with the Spanish speaking line,

you can see week nine was particularly high.

You can see the variation from week

to week in times when ads were tagged or not tagged with--

the Spanish speaking ads were tagged with this de Ayuda

telephone number.

Now, I'm just going to close a little bit

with some of what we've found in our big studies of this.

This was a study that was published last year

in The Lancet that looked at pre and post, a cohort of people

that we looked at pre and post.

And basically, very, very briefly,

we found that about 1.3 million people, if you extrapolated

from the cohort, made a quit attempt who otherwise wouldn't

because of the campaign.

You already saw that we also saw this doubling of calls

to the quit line, that it was remarkably cost effective.

Now, the next year, we did a randomized trial

that was at the regional market level that

is about to be published in two weeks in Tobacco Control.

And this what was a dosing trial, where

we gave an increased dose to people

in some of these randomly selected markets.

And what we found was there was an increase

in quit attempts, ad awareness and disease knowledge.

And this effect was particularly strong, dramatically strong,

in African-Americans.

Their quit attempt rate went from 32% to 51%.

So an incredible finding.

We also found that it was higher in those

with a non-mental chronic disease,

so diabetes, heart disease, cancers, et cetera.

So we've made it.

We're at the end of my little talk,

and I hope you can have some great conversation

in the time remaining around this important topic.

Thank you for your attention.

I'm going to close with this recap of the top line points.

Treatment as a disparity issue is multifaceted.

It requires looking both at how you increase quit attempts

in the process of delivering treatment

and how you increase quit success,

how you have effectiveness, how you increase reach.

Smokers and tobacco users as a category of human beings

suffer currently from significant health disparities,

especially health care access disparities and social justice

concerns that many people are trying to address

but need to be addressed more aggressively.

It is unethical-- let's take the state of Washington--

for the state of Washington to get $1 billion in revenue

from the sale of tobacco products,

but not commit any of that revenue,

or hardly any of that revenue, or its own power as a regulator

of insurers to making certain that everybody's

having to pay that tax, because their addiction

gets assistance.

The good news is that despite low levels of research

over the last 20 or 30 years relative to what

could have been done, we have identified

a set of effective treatments.

And although the barriers to this treatment use

have decreased, they're still far more higher

than we should be tolerating.

And there are multiple priority populations

that I talked about, including many that have a high smoking

burden that have worse access to treatment

and worse patterns of use of treatment.

So we've got to something about that.

And the good news again is, we have solutions

both at the individual level.

Hey, we've got medications, we've got counseling.

But also at the macro level, we have systems changes,

we have societal things that we can do around insurance

coverage and promotion and mixing in

with health care and media campaigns,

et cetera, that work.

So this is a public health issue predominantly

of application, of dissemination,

of policy implementation.

And with that, I will leave you to your devices,

and I wish you the best of luck in the conclusion

of this incredibly important class that you've been taking

and with your careers.

Thank you very much.

Thank you very much for your attention.

Bye bye.