Attachment 2 - Comments

ATTN: Summer King

SAMHSA Reports Clearance Officer

Room 7-1044

One Choke Cherry Road

Rockville, MD 20857

RE: Substance Abuse and Mental Health Services Administration

Proposed Data Collection: 2010 National Mental Health Services Survey

FR Doc. E9-15914

Individuals with mental illness are more than twice as likely to smoke as the general population. The comorbidity of tobacco use and mental illness is a complex phenomenon that is yet to be fully understood. As scientists continue to explore this comorbidity, the American Legacy Foundation (“Legacy”) believes it is important that mental health facilities discourage smoking and provide specifically-designed and evidence-based smoking cessation treatment services to both staff and patients. We urge SAMHSA to include questions in its National Mental Health Services Survey about whether smoking is allowed, by either patients or staff, in those facilities and whether smoking cessation services are made available to patients. This information is important to collect to determine whether smoking is encouraged at mental health facilities, to inform the thoughtful development of policies best suited to ensure a healthy environment for both patients and staff, and to provide cessation treatment services for all smokers who desire to quit.

Legacy is a national, independent public health foundation created in 1999 out of the landmark 1998 Master Settlement Agreement (“MSA”) between the tobacco industry, 46 state governments and five U.S. territories. Our mission is to build a world where young people reject tobacco and anyone can quit. Legacy does not lobby or take positions on specific legislation. Our programs include:

truth® - A national youth smoking prevention media campaign responsible for preventing approximately 450,000 youth from beginning to smoke in its first four yearsⁱ

EX® - An innovative smoking cessation public education campaign designed to help smokers “re-learn” life without cigarettes.

Research Initiatives – Examining the various causes and effects of tobacco use in the United States.

Outreach to Priority Populations – Priority Populations Initiatives and grants provide critical interventions using methods that are culturally competent and tailored for the specific needs of communities disproportionately affected by the toll of tobacco.

Studies have found that 41% of those with a mental health disorder are smokersⁱⁱ, compared with approximately 20% of the general population.ⁱⁱⁱ Of smokers, those with mental illness also smoked more cigarettes on average, than those smokers without mental illness, which leads researchers to conclude that persons with mental illness comprise approximately 44% of the US tobacco market.^iv Because of the high rate of smoking among this population, mental health facilities are an important target setting for reducing tobacco-related health disparities. Unique challenges have historically existed in addressing this complicated comorbidity, however. Smoking by psychiatric patients has often been accepted by health professionals as an individual right and sometimes as self-medication. Several studies suggest that mental health care providers may also smoke at higher levels than the general population.^{vii, v} Additionally, psychiatric inpatient units are exempt from a nationwide ban on smoking in hospitals by the Joint Commission on Accreditation of Healthcare Organizations.^vi

Despite challenges in transitioning psychiatric facilities to smoke-free policies, smoking bans in mental health facilities are not only feasible but have demonstrated positive outcomes.^{vii, viii, ix} In order to abet cessation among patients and staff, smoking bans need to be accompanied by comprehensive smoking cessation services. Smoking restrictions alone have not been shown to be sufficient to reduce smoking rates for patients or staff, ^{vii, x} though smoke-free environments have shown promise in changing patient attitudes and beliefs about quitting. ^{vii, xi}

Smoke-free workplaces and cessation services are important for both patient and staff health. With more and more hospital systems going smoke-free, mental health facilities should follow suit and discourage, if not completely ban, indoor smoking by both patients and employees coupled with providing appropriate cessation programs for patients as well as staff. The American Psychiatric Association practice guidelines recommend the same smoking cessation treatments that are efficacious for the general population be offered to smokers with comorbid psychiatric disorders, and it identifies the inpatient stay as an opportunity to offer these smokers such treatments.^xii Given the dearth of data specific to the United States on the provision of evidence-based smoking cessation services to psychiatric patients and the uncertainty that treatment is systematically provided to such patients, Error: Reference source not found^{, xiii, xiv} the N-MHSS survey provides a starting point for data collection on facilities’ smoking policies. With the addition of questions on smoking within facilities and screening for tobacco use we can begin to understand the prevalence of 100% or partial smoking bans in these types of facilities, and whether or not cessation services are being provided.

Our suggestions for additions to the N-MHSS are listed below:

Include at the appropriate place in the survey the questions:

“Does your facility have an official policy that restricts smoking in any way?¹

(Restrictions include policies of the employer, building owner, or any governmental laws—thus “any policy” at the facility regardless of who is responsible for it.)

Yes No”

“For each of the following indoor areas at your facility, please indicate whether smoking is allowed:²

Public or common areas such as break rooms, cafeteria, hallways or lobby

Yes No

Special smoking room or lounge

Yes No

Patient rooms

Yes No”

“Is smoking allowed anywhere on the property outside the building?³

Yes No”

Include at the appropriate place in the survey the question:

“At intake, are patients asked if they smoke and/or use other tobacco products?

Yes No”

In question A1, revise choice 8 to read:

“8. Substance abuse treatment services (excluding tobacco use treatment)”

And add:

“9. Tobacco cessation services”

In question C1, revise the question to read:

“On April 30, 2010, approximately what percent of the mental health treatment clients enrolled at the facility had diagnosed co-occurring mental health and substance abuse disorders (excluding tobacco use)? _______”

“On April 30, 2010, approximately what percent of the mental health treatment clients enrolled at the facility had diagnosed mental health disorders and use tobacco? ______”

We thank SAMHSA for considering these suggestions. Please contact Stephenie Foster, Senior Vice President of Government Affairs at (202) 454-5559 or sfoster@americanlegacy.org if you have any questions or need further information.

1 Question modified from 2006-2007 Tobacco Use Supplement to the Current Population Survey (TUS-CPS)

2 Modified from California Adult Tobacco Survey 2006

3 Modified from Minnesota Adult Tobacco Survey 2007

i Farrelly MC, Nonnemaker J, Davis KC, Hussin A. The Influence of the National truth Campaign on Smoking Initiation. American Journal of Preventive Medicine, 2009; 36(5): 379-384.

ii Lasser, K, et al. Smoking and Mental Illness: a population-based prevalence study; Journal of the American Medical Association, 2000; 284: 2606-2610.

iii CDC, Cigarette Smoking Among Adults – United States 2007. MMWR, 2009; 57(45): 1221-1226.

iv Lasser, K, et al. Smoking and Mental Illness; Journal of the American Medical Association, 2000; 284: 2606-2610.

v NASMHPD Research Institute, Inc. (2006). Survey on Smoking Policies and Practices for PsychiatricFacilities.

vi Joint Commission on Accreditation of Healthcare Organizations. Accreditation manual for hospitals, 1992. Oakbrook Terrace, IL: Author.

vii Keizer I, Descloux V, Eytan A. Variations in smoking after admission to psychiatric inpatient units and impact of a partial smoking ban on smoking and on smoking-related perceptions. International Journal of Social Psychiatry, 2009; 55(2): 109-123.

viii Lawn S, Pols R. Smoking bans in psychiatric inpatient settings? A review of the research. Australian and New Zealand Journal of Psychiatry, 2005; 39: 866-85.

ix Ibid.

x El-Guebaly N, Cathcart J, Currie S, Brown D, Gloster S. Public health and therapeutic aspects of smoking bans in mental health and addiction settings. Psychiatric Services, 2002; 53: 1617-22.

xi Shmueli D, Fletcher L, Hall SE, Hall SM, Prochaska JJ. Changes in psychiatric patients’ thoughts about quitting smoking during a smoke-free hospitalization. Nicotine and Tobacco Research, 2008; 10(5): 875-881.

xii American Psychiatric Association. Practice guidelines for the treatment of patients with substance use disorders , 2nd edn. APA, 2006. Available from URL: http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm

xiii Wye PM, Bowman JA, Wiggers JH, Baker A, Knight J, Carr VJ, Terry M, Clancy R. Smoking restrictions and treatment for smoking: Policies and procedures in psychiatric inpatient units in Australia. Psychiatric Services, 2009; 60(1): 100-107.

xiv Oliver D, Lubman DI, Fraser R. Tobacco smoking within psychiatric inpatient settings: a biopsychosocial perspective. Australian and New Zealand Journal of Psychiatry, 2007; 41: 572-580.