Tobacco Use Reduction for PLWH: Saving Lives

Tobacco Use Reduction for PLWH: A Systems Level Approach to Saving LivesSheyonna Watson CTTS, Shadena Shipman CTTS MSWPublic Health Consultant MDHHS, Certified Tobacco Treatment Specialist Sacred Heart Rehabilitation Center.

Overview• Present data on Tobacco use for People Living with HIV (PWLH) in the State of

Michigan• Discuss the impact of tobacco use on PLWH• Review Tobacco Use Reduction for PLWH Intervention• Provide lessons learned and resources

24.0

26.1

24.1

25.8

23.4

21.9 22.1

21.1

20.2 19.8

18.9

23.3 23.3

21.4 21.220.7%

20.4%

23.2 22.9 23.1

22

20.8 20.520

19.7

20.5

19.619.3

21.2

19.619.2 18.1

17.5%

16%

13

15

17

19

21

23

25

27

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

%

Michigan USA New BRFSS Weighting & sampling

Increased Price of cigarette

SFA Law

Adult Smoking Prevalence in MI Compared to USA (BRFSS 2000-2016)

24.9%

28%

25.6%

32.3%

41.4%

39.8%

40.3%

46.2%

50%

0% 10% 20% 30% 40% 50% 60%

African American

With disability

Arab American **

Uninsured

LGBT

With poor MentalHealth

Native American

Low SES

HIV-positive person*

Adult Current Smoking Rates by Populations Disproportionately Impacted by Tobacco Use in Michigan, 2016 Behavioral Risk Factor Survey.

* HIV Client Survey 2015** Arab & Chaldean American Survey 2017

State Average = 20.4%

Tobacco Use and PLWH Survey Objectives

• Determine the current cigarette smoking prevalence and pattern among People Living with HIV (PLWH) in Michigan (2015, 2017).

• Assess any change in knowledge, beliefs, behavior, and barriers around smoking and tobacco use among PLWH.

• Study some demographic and socioeconomic factors among PLWH related to tobacco use.

• Assess quitting behavior and the level and the level of readiness to use tobacco dependence treatment available in organizations serving PLWH.

Methods of Survey Distribution• MDHHS-IRB approved the survey• To increase participation rates, we used all methods below:

• Hard copy to be given to all clients visiting the AIDS Service Organizations for any reason

• Online link to Survey Monkey• Phone interview for those in remote areas or whom prefer the phone

interviews. We provided instructions for phone survey• Mailed survey with self addressed return envelope

• Survey opened for 3 months

Characteristics 2015 study 2017 study Statewide prevalence 2017

Total sample 1,478 1,485 15,629

Gender Identity

Male 74% 77% 78%

Female 25% 22% 21%

Transgender 1% 1% 1%

Sample Size and Gender Groups

49.5%*

23%27%

41%*

26%

33%

0%

10%

20%

30%

40%

50%

60%

Current Smoker Former Smoker Never Smoker

20152017

Smoking Status Percentages Among PLWH in 2017 compared with 2015

48%*52%**

58%*

47%*

33%*

45%** 44%*38%*

0%

10%

20%

30%

40%

50%

60%

70%

18-24 years 25-34 years 35-44 years 45 and more

20152017

Percentages of Current Smoking Within Each Age Group Among PLWH in 2017 Compared to 2017

49%* 50%*

38%*

44%*

25%

30%

35%

40%

45%

50%

55%

60%

65%

70%

LGB Heterosexual

2015

2017

Percentages of Current Smoking within each Sexual Orientation Group Among PLWH in 2017 Compared to 2015

51%* 46%**

68%**

40%* 39%**

67%**

0%

10%

20%

30%

40%

50%

60%

70%

80%

Male Female Transgender

20152017

Percentages of Current Smoking within each Gender Identity Group Among PLWH in 2017 compared to 2015

51%* 49%*

57%**

44%**43%*40%*

50%**

39%**

0%

10%

20%

30%

40%

50%

60%

Black Americans White Americans Native Americans Hispanic Latino

20152017

Percentages of current smoking within each Racial Group Among PLWH in 2017 Compared to 2015

44%*

57%*

0%

10%

20%

30%

40%

50%

60%

70%

2015 2017

Percentages of PLWH Smokes Who are Aware of the MI Tobacco QuitLine in 2017 Compared to 2015

1%* 2%** 2%*

10%**

6%**

22%*

6%*

3%**4%*

13%**

7%**

16%*

0%

5%

10%

15%

20%

25%

Counseling Quitline Quit classes PrescribedMedications

OTC medications Cold Turkey

2015

2017

Methods of Quitting Smoking by PLWH who smokes in 2017 Compared to 2015

2015 Focus Group • 14 focus groups were conducted with 92 participants across the state of

Michigan. • The focus group examined tobacco use behavior and how to improve successful

quit attempts• Topics of discussion were

• Influence to quit (Media, environmental changes, health, etc. )• Needs to successfully quit

Media CampaignBased on the feedback from clients in the focus group:

• Developed posters that reflect people of diverse ages, races, and genders participating in positive, healthy activities.

• Created short video with at Tobacco Treatment Specialist (TTS) and PLWH who are smokers sharing their quit journey

Impact of Smoking Cigarettes on PLWH• Quicker progression to advanced

HIV (HIV Stage 3)• Interferes with liver functioning and

processing of medications• Increases likelihood of complications

from medications• Weakens the immune system• On average PLWH die 12.5 years

sooner from tobacco use.

Impact of Smoking Cigarettes on PLWHCommercial Tobacco Products contain tar, chemicals, additives, flavorings, and nicotine that contribute to its harmful effects on the body.

Other Tobacco ProductsAn hour hookah session can be the equivalent of a 10 packs of cigarettesE-Cigarettes are not recommended for tobacco cessation because of they contain carcinogens, flavorings can cause other health complications, and there are varying levels of nicotine.

Barriers to Tobacco Cessation in PLWH

• Lack of knowledge of impact on disease status and medications• Co-morbidity–mental health diagnosis or substance use disorder• Smoking status not asked• Minimal tobacco treatment expertise• Tobacco industry – policy

Program Background• Approached HIV Care Section with need and project concept• Shared student recommendations• Create & implement a pilot project• Tobacco Section would manage and direct the project• Agreed to a 3 year project (Jan 2015-Sept 2017) $1.3 Million each year• Based on the promising results from the 2017 survey, it has moved from a

demonstration/pilot to a fully funded program

Goals and Objectives• Goals:

• Long term – Improve health outcomes for PLWH• Mid term - Increase the # of tobacco quit attempts for PLWH• Short term - ASOs use clinical practice guidelines when treating for tobacco

through creation of tobacco dependence treatment (TDT) policy and process • Objectives/Activities:

• Educate and train ASO staff on tobacco as a priority and treatment resources• Improve data (HIV client and ASO staff)• Document TDT activities through CAREWare• Create expertise in ASOs – trained Tobacco Treatment Specialists• Educate and use Motivational Interviewing for behavior change

Program TimelineYear 1 2015:

Assess Staff, survey clients, train ASO staffYear 2 2016:

Train ASO staff and begin interventionYear 3 2017:

Continue intervention, assess new contractor staff, survey clientsYear 4 2018:

Expand contractors to DEMA (Detroit Eligible Metropolitan Area Ryan White Part A)

Year 5 2019: Peer Demonstration project and specialize treatment

Organizations Providing Tobacco Reduction Services for PLWH FY 2019

Treating Tobacco Dependence as a Chronic DiseaseTobacco Dependence is similar to diabetes, heart failure, hypertension, hyperlipidemia Clinicians should have an expectation for remission and relapseTreatment should be on going and multifaceted:

Advice/counselingSupportAppropriate pharmacotherapy

Treating Nicotine AddictionTobacco use is an addiction that has emotional, physical, and behavioral implications so treatment must address all of these areasTreatments delivered by multiple types of health care providers (nurse, medical assistant, psychologist, social worker or dentist) are more effective than interventions delivered by a single type of clinician

• Ask about tobacco use• Advise to stop• Assess willingness to make an

attempt• Assist in the quit attempt• Arrange follow up visit

5 A’s InterventionAsk: Systematically identify tobacco use at every visitAdvise: Encourage clients to address their tobacco use in a clear, strong, personalized mannerAssess: Determine willingness to make a quit attemptAssist: Provide referrals for medication, counseling, support group, or health education classArrange: schedule follow up either in person or by phone call or text

Tobacco Dependence Treatment At Sacred Heart Rehabilitation Center

TTS meets with clients for individual counselingAttends doctor appointments with clientsEngages clients using Motivational InterviewingCollaborates with Pharmacies to reduce barriers to accessing medicationsHosts health education classes, support groups, and health fairs about tobacco use and living with HIVProvides ongoing monitoring and follow up

Counseling for Tobacco Dependence Treatment

Coping Strategies• The 5 Ds

• Delay, Distract, Drink water, Deep breaths, Discuss• Manage Stress

• Physical activity, writing in a journal, healthy eating• Control the environment

• Tobacco proof the home and car• Talk to support system about the decision to address tobacco us

MedicationsThe seven FDA approved medications for tobacco dependence treatment are covered by the Michigan Drug Assistance Program and Medicaid

• Medications containing Nicotine:• Gum, Inhaler, Lozenge, Nasal spray, Patch

• Non nicotine Medications:• Varenicline (Chantix)• Bupropion (Wellbutrin or Zyban)

Relapse is expectedWhen Clients relapse, the TTS reframes the relapse as a learning opportunity:Learn from it:

• What can I do differently next time?• Review triggers

Stay positive:• Positive self talk• Celebrate any gains

Assess current strategy:• May need to adjust medications, add a strategy, or intervention

Not ready to Quit Clients can still benefit from assessing

tobacco use: What could be a benefit to quitting?Are there any negatives to current tobacco use?What small changes could they make?

Lessons Learned• Providing technical assistance for health systems change activities for health

systems• EMR functionality tool• Including Tobacco Dependence treatment in Quality Management Plan• Revising policies and protocols

• Challenges with integrating TDT services in CAREWare• Importance of gaining buy in from agency staff (case managers, EIS workers,

clinic staff, etc.)• Recognize limitations of Funding• The need for more culturally relevant training• Develop community informed workplans and services

Questions?Sheyonna Watsonwatsons4@Michigan.gov

Shadena Shipmansshipman@sacredheartcenter.com