Journal of the American Psychiatric Nurses Association http://jap.sagepub.com/

Training Psychiatrists and Advanced Practice Nurses to Treat Tobacco Dependence Jill M. Williams, Marc L. Steinberg, Mia Hanos Zimmermann, Kunal K. Gandhi, Gem-Estelle Lucas, Dawn A. Gonsalves, Ivy Pearlstein, Philip McCabe, Magdalena Galazyn and Edward Salsberg Journal of the American Psychiatric Nurses Association 2009 15: 50 DOI: 10.1177/1078390308330458 The online version of this article can be found at: http://jap.sagepub.com/content/15/1/50

Published by: http://www.sagepublications.com

On behalf of:

American Psychiatric Nurses Association

Additional services and information for Journal of the American Psychiatric Nurses Association can be found at: Email Alerts: http://jap.sagepub.com/cgi/alerts Subscriptions: http://jap.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Citations: http://jap.sagepub.com/content/15/1/50.refs.html

>> Version of Record - Mar 10, 2009 What is This?

Downloaded from jap.sagepub.com at RUTGERS UNIV on May 20, 2014

Training Psychiatrists and Advanced Practice Nurses to Treat Tobacco Dependence Jill M. Williams, Marc L. Steinberg, Mia Hanos Zimmermann, Kunal K. Gandhi, Gem-Estelle Lucas, Dawn A. Gonsalves, Ivy Pearlstein, Philip McCabe, Magdalena Galazyn, and Edward Salsberg

The lack of availability of continuing medical education programs on tobacco dependence for psychiatrists and psychiatric nurses is profound. We developed a 2-day curriculum delivered in November 2006 and March 2007 to 71 participants. Ninety-three percent (n = 66) completed a pretest/posttest, and 91% (n = 65) completed the attitudes and beliefs survey. Scores on the pretest were low (M = 47% correct). Paired t tests found significant increases in raw scores from 6.7 to 13.6, t(65) = –22.8, p < .0001. More than 90% of psychiatrists and nurses indicated that motivating and helping patients to stop smoking and discussing smoking behavior were part of their professional role. Although 80% reported that they usually ask about smoking status, fewer reported recommending nicotine replacement (34%), prescribing pharmacotherapy (29%), or referring smokers to a telephone quit line (26%). Trainings are repeated twice a year because of ongoing demand. Further follow-up should evaluate changes in practices after training. J Am Psychiatr Nurses Assoc, 2009; 15(1), 50-58. DOI: 10.1177/1078390308330458

Keywords:   health providers; smoking; tobacco dependence; continuing medical education

Studies have shown increased smoking rates among individuals with a psychiatric disorder compared to the general population. About 76% of current smokers have a past or present psychiatric disorder and estimates indicate that smokers with a current psychiatric disorder consume 44% of all the cigarettes in the United States (Lasser et al., 2000). The consequences of tobacco use in persons with mental illness have also been well documented. Individuals with mental illness have an increased risk for tobacco-caused medical illnesses and nearly 25 years of life lost (Brown, Inskip, & Barraclough, 2000; Lichtermann, Ekelund, Pukkala, Tanskanen, & Lonnqvist, 2001; Miller, Paschall, & Svendsen, 2006; Stroup, Gilmore, & Jarskog, 2000), with cardiovascular deaths causing considerable excess mortality. Despite the frequent use of tobacco, disproportionate tobacco consumption, and excess morbidity and mortality, smokers with mental illnesses have reduced access to tobacco dependence treatment. Smoking cessation services are typically brief, localized to primary care or public health settings, and serve only the highly motivated smoker ready to 50

quit. Smokers with mental illness who experience barriers accessing health care because of disorganized lifestyles and difficulty communicating needs will likely face similar issues accessing communitybased tobacco treatments (Williams, Delnevo, & Ziedonis, in press). In addition, smoking cessation specialists may have limited experience and knowledge about assessment and treatment of mental disorders (Pbert, Jolicoeur, Reed, & Gammon, 2007). Individuals with mental illness may have an increased vulnerability to using tobacco, developing dependence, and experiencing difficulty quitting tobacco (Breslau, Novak, & Kessler, 2004; Hagman, Delnevo, Hrywna, & Williams, 2008; Lasser et al., 2000). These circumstances warrant a specialized treatment approach. For example, certain mental illnesses are associated with more heavy smoking (Beckham, 1999; de Leon, Becona, Gurpegui, Gonzalez-Pinto, & Diaz, 2002), more failed quit attempts, and earlier relapse back to smoking after a quit attempt (Anda et al, 1990; Glassman, 1993; Niaura & Abrams 2001). Practical clinical matters include the fact that tobacco smoke impacts hepatic metabolism of several psychiatric medications that Copyright © 2009 American Psychiatric Nurses Association

Downloaded from jap.sagepub.com at RUTGERS UNIV on May 20, 2014

Treating Tobacco Dependence

might require dose adjustment when individuals quit smoking (Desai, Seabolt, & Jann, 2001; Zevin & Benowitz, 1999). Efforts to improve access to tobacco dependence treatment for smokers with mental illness might be better suited to the behavioral health care setting as compared to primary care settings. Behavioral health specialists have additional training and experience in addiction treatment. They are trained in cognitive-behavioral and motivational enhancement therapies, they generally have more time to spend during patient encounters, and they can offer detailed assessments that include tobacco dependence and its impact on other mental conditions or addictions (Williams & Ziedonis, 2006). Research has shown that the mental health setting is best for providing integrated interventions for other co-occurring substance use disorders (Drake & Mueser, 2001), thus it should also be ideal for addressing tobacco. Targeting psychiatrists and advanced practice nurses as tobacco dependence treatment providers makes sense as they are treatment team leaders on health issues and can help smokers access necessary tobacco treatment medications. Changing behavioral health care professionals’ current practices will be essential before tobacco cessation can be successfully implemented in mental health settings. Nationally representative studies

have documented that psychiatrists counsel smokers less often than other physicians (Easton et al., 2001; Thorndike, Stafford, & Rigotti, 2001). Compared to other physicians, psychiatrists are among the least familiar with state-funded tobacco treatment resources, thus leading to reduced utilization (Steinberg, Alvarez, Delnevo, Kaufman, & Cantor, 2006). Despite recommendations more than 10 years ago for psychiatrists to treat tobacco in all their patients (American Psychiatric Association, 1996), most still do not (Himelhoch & Daumit, 2003; Montoya, Herbeck, Svikis, & Pincus, 2005; Peterson, Hryshko-Mullen, & Cortez, 2003). An additional barrier includes smoking among the health professionals themselves. An international review of tobacco use in the nursing profession reveals declines in smoking rates among nurses over the last 30 years, although rates among U.S. female nurses remain about 30%, higher than the national average (Bain et al., 2004; Smith & Leggat, 2007). There are also variations by specialty, with psychiatric nurses smoking more than those in general practice (Trinkoff & Storr, 1998). This is an important consideration because studies show that health professionals, including nurses who use tobacco, provide fewer cessation services and rate their ability to help patients as lower than colleagues who were former or nonsmokers (Braun et al., 2004; Reeve,

Jill M. Williams, MD, is an associate professor at UMDNJ–Robert Wood Johnson Medical School and UMDNJ–School of Public Health, New Brunswick, NJ; [email protected]. Marc L. Steinberg, PhD, is an assistant professor at UMDNJ–Robert Wood Johnson Medical School and UMDNJ–School of Public Health, New Brunswick, NJ. Mia Hanos Zimmermann, MPH, CTTS, is a research project coordinator at UMDNJ–Robert Wood Johnson Medical School, New Brunswick, NJ. Kunal K. Gandhi, MBBS, MPH, is a research associate at UMDNJ–Robert Wood Johnson Medical School, New Brunswick, NJ. Gem-Estelle Lucas, DO, is a fellow in Child and Adolescent Psychiatry with UMDNJ–Robert Wood Johnson Medical School, New Brunswick, NJ. Dawn A. Gonsalves, MD, is a staff psychiatrist with the Clinic for the Multi-Disabled, Poughkeepsie, NY. Ivy Pearlstein, RN, MSN, APN-C, is a nurse educator at UMDNJ–Robert Wood Johnson Medical School, New Brunswick, NJ. Philip McCabe, CSW, CAS, CDVC, is a health educator at UMDNJ–School of Public Health, New Brunswick, NJ. Magdalena Galazyn, MA, is a research assistant at UMDNJ–Robert Wood Johnson Medical School, New Brunswick, NJ. Edward Salsberg, MPA, is director of the Center for Workforce Studies, Association of American Medical Colleges, Washington, DC. This work was supported by the American Legacy Foundation and an unrestricted educational grant from Pfizer, Inc. The authors are also supported in part by the National Institute on Health (R01-MH076672-01A1 to JMW and K23-DA018203-02 to MLS), and the New Jersey Department of Health and Senior Services, Office of the State Epidemiologist, through funds from New Jersey Comprehensive Tobacco Control Program (JMW, MLS, IP). Dr. Williams was also previously on the Speaker’s Bureau for Pfizer (until June 2008) and she receives grant support from Pfizer. The authors thank Nancy Szkodny and Martha Dwyer from UMDNJ–RWJMS for their assistance with this project. They also thank staff at the Center for Health Workforce Studies at the School of Public Health, University of Albany, including Bonnie Cohen and Gaetano Forte.

Journal of the American Psychiatric Nurses Association,Vol. 15, No. 1 Downloaded from jap.sagepub.com at RUTGERS UNIV on May 20, 2014

51

Williams et al.

Adams, & Kouzekanani, 1996; Slater, McElwee, Fleming, & McKenna, 2006). Although involvement of a health care professional greatly increases the likelihood that patients who try to quit smoking will achieve long-term success (Lancaster, Silagy, & Fowler, 2000), health care professionals are not using their existing skills to help their patients quit. Greater understanding of practice patterns, resources, and existing knowledge and attitudes related to treating individuals who smoke is important in developing strategies to increase health care providers’ sustained participation in cessation activities. In 2005–2006, the Association of American Medical Colleges (AAMC) with the Center for Health Workforce Studies (Albany) conducted a nationwide survey of physicians in four specialty areas (family medicine, internal medicine, obstetrics/gynecology, and psychiatry) to examine knowledge, attitudes, and practice patterns in assisting patients to stop smoking. The cessation practices and attitudes of psychiatrists were significantly different from the other physician specialties, with psychiatrists being least likely to participate in cessation activities (AAMC, 2007). In identifying barriers to practice, psychiatrists also reported the least access to resources and organizational supports for addressing tobacco (AAMC, 2007). Prior to the AAMC survey, little had been known about tobacco dependence treatment knowledge, practices, and attitudes in psychiatric providers. Past tobaccotraining efforts and surveillance of medical professionals had been focused on primary care practitioners and settings. Interventions aimed at training health professionals can be an important first step in increasing the delivery of tobacco dependence treatments (Lancaster et al., 2000). Nurses trained in tobacco dependence interventions were more knowledgeable, had more positive attitudes, and engaged in more activity relating to tobacco dependence treatment (McEwen & West, 2001). Surveying the attitudes of practitioners is also important because more favorable attitudes are associated with higher rates of smoking cessation behaviors (Meredith et al., 2005). Reduced tobacco dependence services in behavioral health care settings may then, at least in part, represent a training or knowledge deficit. In psychiatry residency training programs, tobacco treatment education is not a training requirement, and only half of programs currently provide it (Prochaska, Fromont, Louie, Jacobs, & Hall, 2006). Efforts to more systematically educate student and postgraduate nurses are under way, although there is recent 52

evidence that gaps still exist in nursing curriculum for tobacco (Heath & Crowell, 2007). Although interventions aimed at trainees are important for training the next generation of providers, widespread training for professionals currently in practice is also needed. The availability of continuing medical education (CME) programs on tobacco dependence for psychiatric prescribers are profoundly lacking. The AAMC survey found that few physicians reported being “very well prepared” by prior education to help patients stop smoking and more than 30% of psychiatrists felt that continuing education on cessation was unavailable (AAMC, 2007). There is a need to create new curricula for psychiatrists and advanced practice nurses to make trainings relevant and feasible to their needs. Intensive 5-day tobacco trainings designed to prepare participants to become certified tobacco treatment specialists do not focus on mental health treatment providers’ needs and may be prohibitively long for prescribers to attend. Although some written and online programs exist, live training offers increased opportunity for enhanced active learning by being able to practice skills, ask questions, and interact with training faculty. Live lecture format is also the preferred format for CME by professionals (Stancic, Mullen, Prokhorov, Frankowski, McAlister, 2003). Scheduling a live training over the weekend can minimize time spent away from the office and cause fewer scheduling problems for participants. The goals of this project were to develop and implement a 2-day continuing education curriculum called “Treating Tobacco Dependence in Mental Health Settings.” The educational objectives were to recruit psychiatrist and advanced practice nurse participants and provide them with increased knowledge and skills for the assessment and treatment of smokers with mental illness. The curriculum emphasized motivational and pharmacotherapy techniques for addressing tobacco use in mentally ill smokers and consisted of 11 modules (see Table 1). Although the curricula were tailored to incorporate current knowledge on best practices for treating smokers with mental illness, in areas where knowledge or evidence was lacking, recommendations were taken from clinical practice guidelines for treating smokers in the general population (Fiore et al., 2008). Each participant received a training manual that corresponded with the presentations and contained supplementary learning materials. Category 1 CME credits were included to enhance attendance. The training was offered in November 2006 and March 2007 and was advertised via brochures,

Journal of the American Psychiatric Nurses Association,Vol. 15, No. 1 Downloaded from jap.sagepub.com at RUTGERS UNIV on May 20, 2014

Treating Tobacco Dependence TABLE 1.   Eleven Modules of the Training Curriculum 1. Prevalence of Tobacco Use and Mental Illness and Co    Morbidity 2. Understanding Tobacco Addiction: Neurobiology of Tobacco    Use and Mental Illness 3. Introduction to Motivational Interviewing and Assessing    Motivation to Change 4. Incorporating Assessment of Tobacco Dependence into    Psychiatric Evaluations 5. Pharmacologic Treatments (Part 1) Nicotine Replacement   Therapy 6. Systems Issues Including the Role of the Nurse in Treating   Tobacco in Mental Health Settings 7. Individual and Group Treatments for Tobacco 8. Pharmacologic Treatments (Part II) Non-Nicotine Treatments 9. Treatment Planning Discussion and Exercises: Working with    Lower Motivated Smokers and Complex Cases/Choosing    Pharmacotherapy 10. Master Settlement Agreement, Tobacco Taxes and Tobacco    Control Strategies 11. Tobacco Smoke Interactions with Psychiatric Medications    and Symptom Monitoring

mailings, and Internet listings. Trainings were scheduled on a Friday and Saturday in response to an informal survey of potential participants’ preferences. A program evaluation study was designed to determine the effectiveness of our training on knowledge acquisition (via a pretest/posttest) and feedback about the quality and usefulness of the training (via a training evaluation). The study also included a baseline survey of participants’ demographic information in addition to attitudes and current practices in treating tobacco dependence in smokers with mental illness. METHODS Participants were 71 individuals who registered to attend a 2-day training course focused on training mental health treatment providers to address tobacco dependence. We used an implied consent procedure of a cover letter inviting trainees to participate and explaining our procedures prior to collecting data. The Institutional Review Board of the University of Medicine and Dentistry of New Jersey– Robert Wood Johnson Medical School approved the protocol. At the time of registration on the 1st training day, each participant completed a 15-item multiplechoice pretest. The test included topics from all the training modules including assessment of level of nicotine dependence, knowledge of evidence-based

treatments, and biological links between smoking and mental illness. Participants also completed an 11-item survey that was adapted from an instrument developed by the AAMC–Center for Workforce Studies to make it briefer (11 instead of 28 items). The AAMC survey was collected from more than 3,000 psychiatrists and other physicians as part of a national study conducted to assess physician knowledge, attitudes, and practice patterns related to smoking cessation and tobacco use (AAMC, 2007). Survey questions addressed general knowledge about (a) tobacco use and effectiveness of interventions; (b) physician practice patterns related to smoking cessation; (c) perspectives on issues related to helping patients quit smoking, such as availability of resources and presence of barriers; (d) evaluation of formal training and education; (e) attitudes about smokers and smoking-related issues; and (f) practice characteristics. Results from 801 psychiatrists who participated in the AAMC survey were sent to us as aggregate, deidentified data (frequency of responses only) from the Center for Workforce Studies. The results from the AAMC survey were later compared with the results we obtained from the same items on our briefer version of the survey. This would allow us to compare our results from local practitioners to a national sample of psychiatrists, administered within the same 3-year period. At the conclusion of the 2nd training day, the same 15-item test (posttest) was completed to assess changes in knowledge. Pretest and posttest scores were compared using paired sample t tests. A one-way analysis of variance was used to examine differences in scores between professional groups. Comparisons of variables of categorical type (survey results) were evaluated using chi-square tests unless there were too few responses per cell and then Fisher’s Exact Test was used. Because AAMC data were available only in aggregate results, we were unable to do statistical tests to examine significance of the comparisons so these are reported only as frequency/percentage. Participants also completed training evaluations for each of the 11 modules of the training curriculum. All statistical analyses was performed using SPSS version 16.0. RESULTS Sample Characteristics Forty-one people attended the November 2006 training, and 30 attended in March 2007. Thirty-six (51%) were psychiatrists, 23 (33%) were nurses

Journal of the American Psychiatric Nurses Association,Vol. 15, No. 1 Downloaded from jap.sagepub.com at RUTGERS UNIV on May 20, 2014

53

Williams et al.

(prescribing and nonprescribing), 5 (7%) were psychologists, and 6 (9%) were social workers or other counselors. The professional status of 1 participant is unknown. Participants came from a variety of practice settings: 21 (30%) worked in community mental health, 18 (26%) worked in a psychiatric or general medical hospital, 8 (11%) worked in a solo or group private practice, 4 (6%) worked in a Veterans Affairs setting, 4 (6%) worked in a research or academic settings, and 6 (9%) were senior psychiatry residents or fellows (postgraduate year 4–6). Nine (13%) did not identify in what capacity they worked. Sixty-six percent of participants were female. Ninety-four percent (n = 67) completed the pretest, and 96% (n = 68) completed the posttest, although data analysis was conducted only on complete sets of pre- and posttest scores (n = 66). Ninety-one percent (n = 65) of participants completed the attitudes and beliefs survey. Most attendees were from New Jersey (n = 58, 82%), but 11 (16%) were from other states and 2 (3%) were from outside the United States. Pretest Pretest performance was poor with a mean score of 47% correct (SD = 16; range = 7–93) with no difference in mean pretest scores from participants at the November compared to March training dates, t(64) = –1.345, p = .183. Questions with very low correct responses on the pretest included those on the evidence-based pharmacologic and psychosocial treatments for tobacco dependence, the duration of nicotine withdrawal, and knowledge of tobacco’s effect on drugs metabolized by the cytochrome1A2 system. Pretest questions on motivational interviewing techniques and assessment of tobacco dependence were scored correctly by about half of participants. Psychiatrists scored better than nurses but no better than other professionals with mean pretest scores of 51% correct (vs. 39% nurses and 51% others), F(2) = 4.200, p = .019. Posttest Participants scored significantly better on the post test at the completion of Day 2 of training. Mean posttest score was 91% correct (SD = 10; range = 60–100) and there was no difference in average posttest scores from participants at the November compared to March training dates. Paired t tests comparing pretest to posttest scores of individuals found significant increases in mean raw scores from 6.7 to 13.6, t(65) = –22.8, p < .0001. Psychiatrists, nurses, and other professionals all had significant gains in posttest scores, 54

TABLE 2.   Percentage of Psychiatrists and Nurses Who Responded That These Are Part of Their Role

New Jersey 2-Day Training

Association of American Medical Colleges Survey: Psychiatrists, Nurses, Psychiatrists Yes n Yes n Yes Items (%) (%) p % Help patients    who are    motivated to    stop smoking Motivate patients    to stop smoking Discuss smoking    behavior with    patients Speak with family    about supporting    the patient in    trying to quit    smoking Refer smokers to    others for    treatment Monitor patient    progress in    attempting to    quit Discuss relapse    with patients Establish smoking    cessation    practices for    staff

30 (100)

20 (100)

—

100

30 (100)

20 (100)

—

96

28 (93)

20 (100)

.510

99

24 (80)

20 (100)

.069

73

26 (87)

19 (95)

.636

93

27 (90)

20 (100)

.265

96

27 (90)

20 (100)

.265

98

21 (72)

18 (95)

.068

68



although psychiatrists scored slightly better than nurses and other professionals (93% vs. 85% vs. 88% correct respectively), F(2) = 4.8, p = .011. Provider Survey Because we wanted to compare our findings to those of the AAMC survey (see Tables 2–6), we are presenting data only from psychiatrists (n = 31) and nurses (n = 21). Participants were asked to estimate the percentage of adult patients at their primary practice setting who currently smoke. Forty-four percent of the psychiatrists and nurses surveyed (n = 18) estimated that more than half the patients

Journal of the American Psychiatric Nurses Association,Vol. 15, No. 1 Downloaded from jap.sagepub.com at RUTGERS UNIV on May 20, 2014

Treating Tobacco Dependence TABLE 3.   Percentage of Psychiatrists and Nurses Who “Usually” Engage in Specific Cessation Activities With Patients Who Smoke

TABLE 4.   Percentage of Psychiatrist and Nurse Beliefs About Smoking and Tobacco Dependence Treatment



New Jersey 2-Day Training

Association of American Medical Colleges Survey Psychiatrists Nurses Psychiatrists, Items n (%) n (%) p Usually (%) Ask about    smoking    status Assess patient    willingness to    quit Advise patients    to stop    smoking Refer patients    who smoke to    others for    appropriate    cessation    treatment Recommend    nicotine    replacement    therapy Prescribe other    medication Provide    brochures/    self-help    materials Arrange    follow-up    visits with    patient to    address    smoking Monitor    patient    progress in    attempting to    quit Refer to a quit    line

26 (87)

18 (86)

.639

62

18 (62)

14 (67)

.681

44

25 (83)

16 (76)

.722

62

12 (41)

12 (57)

.433

11

11 (37)

7 (37)

.997

23

10 (35)

7 (37)

.585

20

6 (21)

12 (60)

.006

13

6 (20)

5 (25)

.827

14

12 (40)

9 (43)

.839

28

3 (10)

10 (50)

.007

—

New Jersey 2 Day-Training

Association of American Medical Colleges Psychiatrists: Nurses: Survey: Agree, n Agree, n Psychiatrists Items (%) (%) p Agree, % Smokers choose    to continue    smoking. Most smokers    quit on their own. Smoking is a    chronic relapsing    disorder. Smoking cessation    interferes with    recovery from    chemical    dependency. Physician advice    motivates patients    to quit smoking. Nicotine is the    most addictive    substance used    by my patients. Medication is a    cost-effective    intervention. Use of nicotine    patch increases    successful quitting. Medication is    effective only    when    accompanied by    counseling.

17 (55)

10 (48) .610

47

5 (17)

5 (24) .849

36

30 (97)

17 (81) .149

86

9 (29)

4 (19) .443

23

26 (87)

13 (62) .122

77

26 (84)

17 (81) .920

66

25 (81)

16 (76) .538

62

25 (81)

12 (60) .063

78

16 (52)

14 (67) .557

51

Note. The dash indicates that the question was not part of the original Association of American Medical Colleges survey.

patients stop smoking, and adequacy of prior training in tobacco treatment. A section on facility practices and policies regarding smoking or tobacco that were being followed at the primary practice setting was added for our purposes and not part of the AAMC survey.

in their primary practice setting currently smoke. This estimate was higher than in the AAMC survey, where only 19% of psychiatrists responded that more than half of patients in their setting smoke. Subsequent sections of the survey assessed practitioner attitudes and experience, barriers to helping

Practitioner attitudes and experience. An overwhelming majority of psychiatrists and nurses surveyed felt that it was in their role to help patients stop smoking, including motivating patients to stop. These findings were consistent with those reported in the AAMC survey (see Table 2), although we

Journal of the American Psychiatric Nurses Association,Vol. 15, No. 1 Downloaded from jap.sagepub.com at RUTGERS UNIV on May 20, 2014

55

Williams et al.

found slightly lower rates of affirmative response for psychiatrists speaking with the family (80%) and establishing smoking cessation practices for staff (72%). None of the responses reported in Table 2 were significantly different between psychiatrists and nurses. Most psychiatrists (87%) and nurses (86%) reported usually asking patients about smoking status (see Table 3). Responses were lower for assessing patients’ willingness to quit (62% of psychiatrists and 67% of nurses), recommending nicotine replacement therapy (37% of psychiatrists and 37% of nurses), or referring patients for tobacco dependence treatment (41% of psychiatrists and 57% of nurses). More nurses than psychiatrists referred patients to a quit line (50% vs. 10%; χ2 = 9.88, p = .007) and provided brochures and self-help materials (60% vs. 21%; χ2 = 10.34, p = .006). About half of psychiatrists (55%) and nurses (48%) felt that smokers “choose to continue smoking,” and many felt that nicotine was the most addictive substance used by their patients, responses that were not significantly different between groups (see Table 4). Barriers to helping patients quit smoking. Participants identified barriers to helping patients try to stop smoking and some were significantly different between psychiatrists and nurses (see Table 5). More psychiatrists than nurses indicated that limited time with patients was a somewhat or significant barrier (80% vs. 50%, Fisher’s exact; p = .034). Psychiatrists also report more often that other practice priorities reduce their ability to address smoking with patients (90% vs. 52%, Fisher’s exact; p = .004). More psychiatrists also identified limited insurance reimbursement as a barrier than nurses (73% vs. 35%, Fisher’s exact; p = .010). Of interest, more psychiatrists perceived that their limited experience in intervening with smokers was a barrier (79% vs. 43%, Fisher’s exact; p = .016). Limited learning opportunities. More than 60% of psychiatrists and nurses felt that their graduate education left them “not at all prepared” for treating tobacco (see Table 6). None of the responses reported in Table 6 were significantly different between psychiatrists and nurses. Many psychiatrists and nurses felt that postdegree continuing education had not prepared them at all for treating tobacco, which was comparable to the AAMC survey. Tobacco-free worksite. Our survey asked participants to indicate which tobacco use and dependence 56

practices or policies were being followed at their primary practice setting. Responses to this question are given in aggregate for psychiatrists and nurses who presumably work in similar practice settings. Of note is that a sizeable portion of responses to this question were “Don’t know” (up to 32%) or were missing (up to 20%). This may represent significant lack of awareness of local tobacco policy. Although most (78%) endorsed knowledge of written policies prohibiting tobacco use in buildings, only 32% said staff and patient use of tobacco is segregated. Nearly half (49%) do not have tobacco-free grounds at their facility (i.e., smoking is allowed outdoors). One third did not know if there were clear consequences for patients or staff members who violate tobacco policies. Training Evaluation Seventy-one participants completed evaluations each day to rate the quality of the training. These included ratings of each instructor as well as the overall session content and information. Evaluations were very positive in endorsing both learning from individual sessions and effectiveness of instructors. We summarized responses from evaluations of 10 course sections. Responses were rated from 1 (not at all) to 5 (very much so). An average of 87% agreed that they learned new skills during each session (measured as a 4 or 5 on the evaluation). An average of 90% agreed that each session was worthwhile (measured as a 4 or 5 on the evaluation). Participants were also invited to include additional comments. Many described the training experience as “excellent” and “worthwhile,” reporting that they planned to apply what they learned. Evaluations of the training were very positive and included comments such as, “I would strongly recommend other psychiatrists to attend” and “I learned many strategies to help clients stop smoking.” DISCUSSION We developed and implemented a successful 2-day continuing education curriculum, titled Treating Tobacco Dependence in Mental Health Settings. Baseline knowledge of assessment and treatment of tobacco dependence was poor; clinicians lacked basic information about nicotine withdrawal and pharmacological and psychosocial treatments. The significant increase in knowledge and positive attitudes on the survey reflect a desire by psychiatrists and nurses to become better

Journal of the American Psychiatric Nurses Association,Vol. 15, No. 1 Downloaded from jap.sagepub.com at RUTGERS UNIV on May 20, 2014

Treating Tobacco Dependence

informed. More than 90% of participants indicated that helping patients to stop smoking was part of the psychiatrist’s or mental health nurse’s role. Although 80% reported that they usually ask about smoking status, fewer reported recommending or providing treatment. Few felt that prior graduate or postgraduate education had fully prepared them to help patients quit smoking. Beliefs and attitudes about treating tobacco were often shared among nurses and psychiatrists, although psychiatrists identified more barriers because of time, other practice priorities, and insurance reimbursement. Limitations of the evaluation study include that we were not able to assess actual changes in treatment practices of these professionals who completed this training. Many of the results from the attitudes and beliefs survey we conducted were similar to those observed by the nationally representative survey of the AAMC. Mental health professionals value treating tobacco but have limited experience and training and the competing demands of a modern practice. It is also not surprising that there would be some differences in responses between the two surveys because we sampled a group seeking additional training in treating tobacco. Future initiatives might include actual chart review of cases seen by practitioners receiving such training in order to better demonstrate the effect of this educational experience on specific clinical behaviors. At this time, the 2-day training has been implemented five times and there are plans to continue to offer it twice a year due to ongoing demand from behavioral health providers. In addition to providing it on site in New Jersey, there have been requests to bring the curriculum to other states. Although the training was originally marketed to psychiatrists and advance practice nurses, it continues to attract a broad range of mental health professionals. Although we started this project more than 3 years ago, there continues to be almost no other available continuing education resources for treating tobacco dependence in smokers with mental illness. Live training courses such as this one can be modified into print materials (i.e., journals and periodicals) or Web-based courses to reach a larger audience and growing demand for training in this critical area. REFERENCES American Psychiatric Association. (1996). Practice guideline for the treatment of patients with nicotine dependence. Washington, DC: Author.

Anda, R. F., Williamson, D. F., Escobedo, L. G., Mast, E. E., Giovino, G. A., & Remington, P. L. (1990). Depression and the dynamics of smoking. A national perspective. Journal of the American Medical Association, 264, 1541-1545. Association of American Medical Colleges. (2007, May). Physician behavior and practice patterns related to smoking cessation (Full report). Washington, DC: Author. Bain, C., Feskanich, D., Speizer, F. E., Thun, M., Hertzmark, E., Rosner, B. A., et al. (2004). Lung cancer rates in men and women with comparable histories of smoking. Journal of the National Cancer Institute, 96, 826-834. Beckham, J. C. (1999). Smoking and anxiety in combat veterans with chronic posttraumatic stress disorder: A review. Journal of Psychoactive Drugs, 31, 103-110. Braun, B. L., Fowles, J. B., Solberg, L. I., Kind, E. A., Lando, H., & Pine, D. (2004). Smoking-related attitudes and clinical practices of medical personnel in Minnesota. American Journal of Preventive Medicine, 27, 316-322. Breslau, N., Novak, S. P., & Kessler, R. C. (2004). Psychiatric disorders and stages of smoking. Biological Psychiatry, 55, 69-76. Brown, S., Inskip, H., & Barraclough, B.  (2000). Causes of the excess mortality of schizophrenia.  British Journal of Psychiatry, 177, 212-217. de Leon, J., Becona, E., Gurpegui, M., Gonzalez-Pinto, A., & Diaz, F. J. (2002). The association between high nicotine dependence and severe mental illness may be consistent across countries. Journal of Clinical Psychiatry, 63, 812-816. Desai, H. D., Seabolt, J., & Jann, M. W. (2001). Smoking in patients receiving psychotropic medications: A pharmacokinetic perspective. CNS Drugs, 15, 469-494. Drake, R. E., & Mueser, K. T. (2001). Managing comorbid schizophrenia and substance abuse. Current Psychiatry Reports, 3, 418-422. Easton A., Husten C., Elon L., Pederson L., & Frank E. (2001). Nonprimary care physicians and smoking cessation counseling: Women physicians’ health study. Women & Health, 34(4),15-29. Fiore, M. C., Jaén, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., Curry, S. J., et al. (2008). Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services Public Health Service. Glassman, A. H. (1993). Cigarette smoking: Implications for psychiatric illness. American Journal of Psychiatry, 150, 546-553. Hagman, B. T., Delnevo, C. D., Hrywna, M., & Williams, J. M. (2008). Tobacco use among those with serious psychological distress: Findings from the National Survey of Drug Use and Health, 2002. Addictive Behaviors, 33, 582-592. Heath, J., & Crowell, N. A. (2007). Factors influencing intentions to integrate tobacco education among advanced practice nursing faculty. Journal of Professional Nursing, 23, 189-200. Himelhoch, S., & Daumit, G. (2003). To whom do psychiatrists offer smoking-cessation counseling? American Journal of Psychiatry, 160, 2228-2230. Lancaster, T., Silagy, C., & Fowler, G. (2000). Training health professionals in smoking cessation (Cochrane Review). Cochrane Database of Systematic Reviews, 2000(3), CD000214. Lasser, K., Boyd, J. W., Woolhandler, S., Himmelstein, D. U., McCormick, D., & Bor, D. H.  (2000). Smoking and mental illness: A population-based prevalence study.  Journal of the American Medical Association, 284, 2606-2610. Lichtermann, D., Ekelund, J., Pukkala, E., Tanskanen, A., & Lonnqvist, J. (2001). Incidence of cancer among persons with

Journal of the American Psychiatric Nurses Association,Vol. 15, No. 1 Downloaded from jap.sagepub.com at RUTGERS UNIV on May 20, 2014

57

Williams et al. schizophrenia and their relatives. Archives of General Psychiatry, 58, 573-578. McEwen, A., & West, R. (2001). Smoking cessation activities by general practitioners and practice nurses. Tobacco Control, 10, 27. Meredith L. S., Yano E. M., Hickey S. C., & Sherman S. E. (2005, September). Primary care provider attitudes are associated with smoking cessation counseling and referral. Med Care, 43, 929-934. Miller, B. J., Paschall, C. B., III, & Svendsen, D. P. (2006). Mortality and medical comorbidity among patients with serious mental illness. Psychiatric Services, 57, 1482-1487. Montoya, I. D., Herbeck, D. M., Svikis, D. S., & Pincus, H.A. (2005). Identification and treatment of patients with nicotine problems in routine clinical psychiatry practice. American Journal on Addictions, 14, 441-454. Niaura, R., & Abrams, D. B. (2001). Stopping smoking: A hazard for people with a history of major depression? Lancet, 357, 1900-1901. Pbert, L., Jolicoeur, D., Reed, G., & Gammon, W. L. (2007). An evaluation of tobacco treatment specialist counseling performance using standardized patient interviews. Nicotine & Tobacco Research, 9, 119. Peterson, A. L., Hryshko-Mullen, A. S., & Cortez, Y. (2003). Assessment and diagnosis of nicotine dependence in mental health settings. American Journal on Addictions, 12, 192-197. Prochaska, J. J., Fromont, S. C., Louie, A. K., Jacobs, M. H., & Hall, S. M. (2006). Training in tobacco treatments in psychiatry: A national survey of psychiatry residency training directors. Academic Psychiatry, 30, 372-378. Reeve, K., Adams, J., & Kouzekanani, K. (1996). The nurse as exemplar: Smoking status as a predictor of attitude toward smoking and smoking cessation. Cancer Practice, 4, 31-33. Slater, P., McElwee, G., Fleming, P., & McKenna, H. (2006). Nurses’ smoking behaviour related to cessation practice. Nursing Times, 102, 32-37.

58

Smith, D. R, & Leggat, P. A. (2007). An international review of tobacco smoking research in the nursing profession, 1976– 2006. Journal of Research in Nursing, 12, 165-181. Stancic, N., Mullen, P. D., Prokhorov, A. V., Frankowski, R. F., & McAlister, A. L. (2003). Continuing medical education: What delivery format do physicians prefer? The Journal of Continuing Education in the Health Professions, 23, 162-167. Steinberg, M. B., Alvarez, M. S., Delnevo, C. D., Kaufman, I., & Cantor, J. C. (2006). Disparity of physicians’ utilization of tobacco treatment services. American Journal of Health Behavior, 30, 375-386. Stroup, T. S., Gilmore, J. H., & Jarskog, L. F. (2000). Management of medical illness in persons with schizophrenia. Psychiatric Annals, 30, 35-40. Swartz, M. S., Swanson, J. W., Hannon, M. J., Bosworth, H. S., Osher, F. C., Essock, S. M., et al. (2003). Five-Site Health and Risk Study Research Committee. Regular sources of medical care among persons with severe mental illness at risk of hepatitis C infection. Psychiatric Services, 54, 854-859. Thorndike, A. N., Stafford, R. S., & Rigotti, N. A. (2001). US physicians’ treatment of smoking in outpatients with psychiatric diagnoses. Nicotine & Tobacco Research, 3, 85-91. Trinkoff, A. M., & Storr, C. L. (1998). Substance use among nurses: Differences between specialties. American Journal of Public Health, 88, 581-585. Williams, J. M., Delnevo, C., & Ziedonis, D. M. (In press). The unmet needs of smokers with mental illness or addiction. In P. Bearman, K. Neckerman, & Leslie Wright (Eds.), Social and Economic Consequences of Tobacco Control Policy. New York: Columbia University Press. Williams, J. M., & Ziedonis, D. M. (2006) Snuffing out tobacco dependence: Ten reasons behavioral health providers need to be involved. Behavioral Healthcare, 26, 27-30. Zevin, S., & Benowitz, N. L. (1999). Drug interactions with tobacco smoking. An update. Clinical Pharmacokinetics, 36, 425-438.

Journal of the American Psychiatric Nurses Association,Vol. 15, No. 1 Downloaded from jap.sagepub.com at RUTGERS UNIV on May 20, 2014