Creating a Culture of Change:Tobacco Cessation Strategies for Long-Term TreatmentAmber Norwood, Ph.D.

Assistant Professor of Psychology, Shippensburg University

Maryland Licensed Psychologist

Acknowledgements

• Thank you to MDQuit for having me today! I am a proud former team member J

• Thank you to all of my former colleagues at Springfield Hospital Center (SHC); we did wonderful work in tobacco cessation together!

◦ Especially the Addiction, Co-Occurring Disorders, and Trauma Recovery Services (ACTRS) Department

• Thank you to my psychology graduate assistant, Ashley Conley, who assisted in the preparation (and beautification!) of these slides.

Goals for today!• Brief review of the literature concerning tobacco/nicotine use (including nicotine vaping) in

behavioral health clients

• Concrete suggestions for how to assess current culture/attitudes of your organization

• Discussion of potential barriers (and solutions) to tobacco cessation in long-term treatment

• An overview of the ways that various providers can be involved in a culture of tobacco cessation at their agency

• Discussion of systemic, group, and individual strategies for addressing tobacco cessation in long-term treatment settings

• Woven throughout = Prior examples from my work at a state psychiatric hospital

• 10 min Q&A at the end!

A Note on Terminology

Title of webinar references ‘tobacco cessation’ and I will use

this terminology throughout

However, note that I am talking about all types of tobacco/nicotine use

(cigarette smoking, chew/dip, nicotine vaping, cigars, etc.)

And saying ‘tobacco use change’ may be even more appropriate than cessation,

as my view and the strategies I’ll be reviewing support clients wanting to

make *ANY* change/reduction in their tobacco use

Background

• In 2016, 35% of adults with mental illness and 23% of adults without mental illness reported use of tobacco1

◦ Individuals with mental illness are more likely to be addicted to tobacco

◦ Schizophrenia has the highest rate of tobacco use, at 90%

◦ All types of substance use are higher for individuals who use tobacco products

• Less than half of mental health and substance use treatment facilities offered tobacco cessation treatment1

Background

• Outpatient screening & cessation assistance2

◦ 63% of visits included screening for tobacco use

◦ 24.5% of visits included tobacco cessation assistance

• Medication + counseling appears to be a more effective strategy than counseling alone (for some populations)4

◦ Varenicline tartrate (Chantix) + Quitline counseling

Background: Treatment Strategies

• Motivational counseling, preparation to quit, & nicotine patch6

◦ More likely to quit at 3-months & continue treatment

◦ Motivational interventions may increase engagement

• Motivational counseling during psychiatric care with smoking ban7

◦ Smoking reductions at 3, 6, 12, and 18 months post-treatment

◦ Counseling patients less likely to have subsequent psychiatric hospitalizations compared to no treatment

Background: Education & Attitudes

• Attitudes toward nicotine replacement therapy (NRT)9

◦ Before NRT education, patients believed smoking + NRT to be unsafe, that NRT does not reduce harm, that there are no health benefits, and that financial costs would be higher

◦ After education, 67% of patients agreed to consider NRT

Background: Education & Attitudes

• Mental health practitioners’ attitudes toward tobacco cessation10

◦ 78% of the practitioners asked about smoking, 67% provided education

◦ 31%-40% provided direct assistance with tobacco cessation

◦ Practitioners unsure about safety (57%) and efficacy (39%) of e-cigarettes

◦ Mental health practitioners who were current smokers were less likely to adhere to the 5As of smoking cessation (ask, assess, advise, assist, and arrange follow up)

◦ Importance of tobacco cessation training for mental health practitioners

SBIRT & Brief Interventions (Review!)• What is SBIRT

◦ Screening, Brief Intervention, Referral to Treatment◦ Evidence-based interaction aimed at increasing motivation for treatment

◦ Screening is universal◦ Specific behaviors related to tobacco use (in this case!) are targeted

◦ Brief (~5 min)◦ Services occur in a any treatment setting

◦ Differs from therapy (personnel, length of interaction, setting)

• Strong empirical evidence – still accumulating

Brief Intervention: A3C (Review!)

AskAbout tobacco use

AdviseProvide personalized recommendation to quit

AssessDetermine willingness to change tobacco use

behavior – cut down, quit

ConnectIF READY, connect to available resources

Assess

• Tell me about any changes you’d like to make when it comes to your tobacco use.• When you are discharged from the hospital, what do you plan to do

about your tobacco use? (different questions for your agency)• Use a readiness ruler

◦ ‘On a scale of 1 to 10 with 1 being not all ready and 10 being completely ready to make a change…”

Connect

• We will talk about how to build the Connect today◦ Think about what you can offer at your agency

◦ What services you might need to make referrals for

Every setting has its own unique challenges and strengths.

Let’s talk through some systemic, group, and individual level approaches to creating a culture that supports tobacco cessation for all clients.

Long-Term Treatment Settings

• Inpatient psychiatric hospital

• Individual provider level is one point of intervention ◦ Greater success with a culture of support across organization levels,

all providers, all staff

Systemic Level/Administrative Support

• When talking with administrators and seeking support for tobacco cessation initiatives,

* connect tobacco cessation with agency goals/objectives* use data

***Remember – MDQuit has online Administrator trainings also!

Interdisciplinary Team of Action

• Tobacco Cessation Task Force ---- why?◦ Addiction psychologist

◦ Pharmacist

◦ Psychiatrist

◦ Social Worker

◦ Nurse

• Think about who might make up a group like this at your agency!

Assessing Your Organization’s Culture• Examples from SHC (surveys)

◦ Surveyed patients

◦ Surveyed prescribers

◦ In our case, we didn’t survey those providing behavioral interventions because our department delivered those services and all were on board.

• Quasi-program evaluation

◦ Before we can enact change, we have to know where we’re starting

Patient Survey: Relevant Findings

• Majority of those in tobacco cessation groups reported satisfaction with their experience in group

• Over half said they wanted to cut down; over half said they wanted to quit tobacco altogether

• 40% said they’d like to talk to the doctor about NRT and would consider trying it as a cessation tool

Prescriber Survey:Relevant Findings

***referrals to addiction dept. for tobacco use only

What would help address barriers to prescribing NRT:

*written information on dosing guidelines for NRT

*ACTRS consultation with recommendations for NRT type, with dosing guidelines

*Pharmacy consultation on a case-by-case for choosing NRT type and appropriate dosing

Engaging an Entire System Together

• One way we engaged all providers/staff (or as many as possible!) at SHC was through the use of hospital-wide trainings

◦ If your agency already does these, this may be a window of opportunity

◦ Trainings were provided first as initial educational opportunities and then tailored to the needs of our staff/setting based on the needs assessment surveys

Engaging an Entire System Together• Examples of trainings we used:

◦ Dr. Fishman – Pharmacologic Interventions & Management

◦ Dr. DiClemente – Behavioral interventions, brief interventions

◦ SHC provider led (myself, pharmacist, psychiatrist)

◦ Available tobacco cessation behavioral interventions and intro to SBIRT for all providers

◦ Taught all staff to deliver A3C

◦ Pharmacy presentation safety, efficacy, & dosage guidelines of NRT and anti-craving medications

◦ Medical staff guidelines re: prescription of NRT and/or anti-craving medications

Engaging an Entire System Together: Responding to Needs

Pharmacy guidelines‘Curbside’ Consults

Medical staff guidelines

Tobacco Cessation Resource Binder(available on all hospital units)

Ongoing support for behavioral interventions

(available on all hospital units)

Tobacco Cessation Resource Binder

Topic Page #

Why do we need a Tobacco Cessation Resource Binder? 3

Tobacco Use Facts & Figures 4

Use among adults with psychiatric & substance use disorders 4

Tobacco 101 Fact Sheet: Behavioral Health Clients 5

Tobacco 101 Fact Sheet: Special Populations 6

Tobacco 101 Fact Sheet: Second & Thirdhand Smoke 8

Tobacco 101 Fact Sheet: E-Cigarettes 10

An Assessment for Everyone - SBIRT: A3C Model 12

Behavioral Interventions for Tobacco Cessation at SHC 13

Smoking and Psychiatric Medications 14

Pharmacologic Interventions for Tobacco Cessation at SHC 15

Tobacco Cessation Medication Order Forms 16

Frequently Asked Questions 18

Smoking Cessation Discharge Checklist 21

How can Providers Support Tobacco Cessation?• Checking in about tobacco use (including vaping) at every interaction

• SBIRT (supporting any attempts to change)- A3C

• Prescribing NRT and/or medications to support tobacco cessation when appropriate

• Facilitating evidence-based individual and group tobacco cessation services

• Asking about tobacco use and making appropriate plans for discharge

◦ Adjusting medications

◦ Prescribing NRT

◦ Follow-up group and individual therapy referrals

Interventions at the Individual & Group Level – Examples!

Addiction assessment

Identify tobacco use severity

(including vaping!) and prior use of

NRT

Assess readiness to address

tobacco use while at SHC

Provide appropriate treatment

recommendations

Tobacco cessation groups (and individual therapy)

12 weeks (BH2 – protocol adapted

for our hospital population)

CBT-based with motivational

enhancement

Encourage autonomy and patient-

directed change process

Upon discharge

Maryland Quitline Fax to Assist

When a culture of change happens…• NRT/medications to support change in tobacco use are prescribed as needed

• Interdisciplinary approach to supporting clients’ change

• Referrals to higher levels of treatment/care as needed

• Individual and group interventions to support tobacco cessation

• Assessment of tobacco cessation needs prior to discharge from your agency

• Of course, there will be bumps in the road

• Change is a process, not a product◦ (Someone we all like quite a lot is well known for this statement and it certainly applies here!)

THANKS FOR BEING HERE!

THOUGHTS/QUESTIONS?

References9Bittoun, R., Barone, M., Mendelsohn, C. P., Elcombe, E. L., & Glozier, N. (2014). Promoting positive attitudes of tobacco-dependent mental health patients towards NRT-supported harm reduction and smoking cessation. Australian and New Zealand Journal of Psychiatry, 48(10), 954–956. https://doi.org/10.1177/0004867414535673

4Carson, K. V., Smith, B. J., Brinn, M. P., Peters, M. J., Fitridge, R., Koblar, S. A., Jannes, J., Singh, K., Veale, A. J., Goldsworthy, S., Litt, J., Edwards, D., Hnin, K. M., & Esterman, A. J. (2014). Safety of varenicline tartrate and counseling versus counseling alone for smoking cessation: A randomized controlled trial for inpatients (STOP study). Nicotine & Tobacco Research, 16(11), 1495–1502. https://doi.org/10.1093/ntr/ntu112

1Centers for Disease Control and Prevention. (2020). Tobacco Use and Quitting Among Individuals With Behavioral Health Conditions. https://www.cdc.gov/tobacco/disparities/mental-illness-substance-use/index.htm

6Christiansen, B. A., Carbin, J., TerBeek, E., & Fiore, M. C. (2018). Helping smokers with severe mental illness who do not want to quit. Substance Use & Misuse, 53(6), 949–962. https://doi.org/10.1080/10826084.2017.1385635

5Cooney, J. L., Cooper, S., Grant, C., Sevarino, K., Krishnan-Sarin, S., Gutierrez, I. A., & Cooney, N. L. (2017). A randomized trial of contingency management for smoking cessation during intensive outpatient alcohol treatment. Journal of Substance Abuse Treatment, 72, 89–96. https://doi.org/10.1016/j.jsat.2016.07.002

2Jamal, A., Dube, S. R., & King, B. A. (2015). Tobacco use screening and counseling during hospital outpatient visits among US adults, 2005–2010. Preventing Chronic Disease: Public Health Research, Practice, and Policy, 12. doi: 10.5888/pcd12.140529

3Khara, M., Okoli, C., Nagarajan, V. D., Aziz, F., & Hanley, C. (2015). Smoking cessation outcomes of referral to a specialist hospital outpatient clinic. The American Journal on Addictions, 24(6), 561–570. https://doi.org/10.1111/ajad.12259

7Prochaska, J. J., Hall, S. E., Delucchi, K., & Hall, S. M. (2014). Efficacy of initiating tobacco dependence treatment in inpatient psychiatry: A randomized controlled trial. American Journal of Public Health, 104(8), 1557–1565. https://doi.org/10.2105/AJPH.2013.301403

8Schulte, D. M., Duster, M., Warrack, S., Valentine, S., Jorenby, D., Shirley, D., Sosman, J., Catz, S., & Safdar, N. (2016). Feasibility and patient satisfaction with smoking cessation interventions for prevention of healthcare-associated infections in inpatients. Substance Abuse Treatment, Prevention, and Policy, 11. https://doi.org/10.1186/s13011-016-0059-0

10Sharma, R., Meurk, C., Bell, S., Ford, P., & Gartner, C. (2018). Australian mental health care practitioners’ practices and attitudes for encouraging smoking cessation and tobacco harm reduction in smokers with severe mental illness. International Journal of Mental Health Nursing, 27(1), 247–257. https://doi.org/10.1111/inm.12314