Smoking Cessation Support for Mental Health Services Clients on PEI

Background research on cessation success, frontline worker training, and group

programs

Prepared by Vicki Bryanton

September 2008

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Background Research Objective

To review the research on smoking cessation among those living with mental illness and review the

available target-focused cessation programs for consideration and adaptation for use on Prince Edward

Island.

Research Review Limitations

This investigation was limited to:

Smoking cessation research materials and available group programs as it related to people living

with mental illness (and to a lesser degree – addictions.) The search was not limited to North

America but extended internationally.

Information and training materials/programs for mental health care workers to support their

clients’ cessation efforts.

Information that related to mental health care workers and their own cessation efforts.

The writer’s knowledge and 18 years of experience with smoking cessation work on PEI

Inclusion Criteria for Program Choices

Programs needed to have a focus on cessation for people living with mental illness (with or without

addiction issues), be available for use on PEI, be sustainable (training could be received locally – on an

ongoing basis and materials needed to be economically reproduced), and be flexible enough to fit within

the Project timeline and resources.

Included in this Report

This review includes sections on Background and Information Planning, Group Programs for Mental

Health Clients, Training Programs for Frontline Workers, and Recommendations that cover:

An annotated bibliography of recommended materials reviewed for background and planning

support that provided information on:

o The prevalence of tobacco use among people with mental illness,

o The factors associated with tobacco use by people with mental illness,

o The challenges of smoking cessation for people with mental illness, and

o Strategies and approaches to facilitate smoking cessation by people with mental illness.

Identification of key materials/information to aid in completion of Smoking Cessation Project

Programs outlined

Recommendations for future action

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Background and Planning Information

el-Guebaly, Nady, et al. (2002) Smoking Cessation Approaches for Persons With

Mental Illness or Addictive Disorders. Psychiatr Serv 53 (9): 1166-1170.

This is a good review of cessation success rates using different cessation support techniques. Quit rates

on various studies ranged from 31 percent to 72 percent at the end of treatment and from 11.8 percent

to 46 percent at 12 months. This information should be used when designing PEI’s group program. It

also provides outcomes measures other than cessation alone that should be considered for Evaluation

purposes.

Brown, Carol. (2004)Tobacco and Mental Health: A Literature Review. Action on

Smoking and Health (Scotland). Edinburgh, Scotland. www.ashscotland.org.uk

This ASH (Action on Smoking and Health – Scotland) review was conducted to find out more about the

pertinent issues around tobacco use among adults with mental health difficulties in Scotland. The

review was conducted during May 2003 and June 2004. Existing research, policy documents and other

texts revealed key themes and gaps in the knowledge base.

Themes identified and relevance to PEI project:

Legal and policy context which impacts upon service provision for adults with mental

health problems – although legal and policy issues would differ somewhat in Canada,

the success of this first PEI program and its potential integration into our health care

system may depend on the “success” of this pilot work – for these reasons, focusing on

people outside of inpatient institutional settings would be recommended.

Prevalence of tobacco use among people experiencing mental illness, explanations for

the high rates of smoking and a discussion of the impact of smoking on health – this

section is a good starting point for PEI’s project (we have little in the way of detailed

Canadian data, but what we do have mimics the information internationally.)

Benefits and challenges of stopping smoking - good information for facilitators and

facilitator trainer to understand as they approach a new cessation program/ also good

information for coordinator when working with marketing plan to drive smokers to

existing programs

Approaches to smoking cessation and smoking policies – includes clinical practice

guidelines for smoking cessation and reduction for patients with schizophrenia (created

by SANE, an Australian mental health organization) that sound very much like the 4A’s

approach used in Canada: ASK - find out if their patients smoke, ASSESS - assess their

readiness to quit, ASSIST - assess the risks associated with stopping smoking, devise a

plan for quitting, ARRANGE - use NRT, recommend group support and monitor progress

frequently.

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A brief section, “mental illness: symptoms, causes and treatments”, is a very good overview for those

unfamiliar with mental illnesses and might be useful in educating those unfamiliar with the special

needs of these groups.

ASH. (2004) The Third Phase of ASH Scotland's Tobacco and Inequalities Project

2003-2006. Action on Smoking and Health (Scotland). Edinburgh, Scotland.

www.ashscotland.org.uk

This briefing paper is a good “mental health and smoking” backgrounder (information taken from

Tobacco and Mental Health: a Literature Review.) It also states a list of “good practise” in tobacco use

with mental health service users. This would be useful in creating resources for PEI’s front line workers.

Research suggests that mental health problems do not undermine the ability to stop smoking. Studies

indicate that stopping smoking does not appear to exacerbate psychotic symptoms and that experience

of depression does not affect quit rates. To continue to make exemptions for people experiencing

mental health difficulties is discriminatory and will continue the risk of smoking related disease in this

community.

Recommendations and examples of good practice:

Involving all health and social care services in responding to the unmet physical health

needs of mental health service users. This includes both primary and secondary care,

and non-health services. Initiatives to tackle tobacco use are an integral part of any such

strategy. {This supports the focus of the PEI project to engage health system and

community -- both those living with mental illness and those supporting smoking

cessation efforts.}

Providing tobacco education and smoking cessation training for nurses and other

caregivers. {Although PEI’s project focuses on mental health care workers first, it

shouldn’t preclude opportunities to reach those nurses running Quit Care.}

Provision of smoking cessation information and services that are clearly relevant to

people with mental health problems and that involve service users in their

development, pre-testing and piloting {This supports the PEI plan to trial directed

materials and to focus test these materials.}

Targeted health promotion campaigns and printed resources that are focused towards

people with mental health problems and specifically address mental health service

users' diagnoses, symptoms and treatments. {This could be used in focusing the contact

with front line workers.}

The implementation of policies designed to restrict the times and places which service

users, staff and visitors are allowed to smoke. {Fortunately, for PEI, we already have

this policy support to a large degree.}

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Pipe, Andrew and Charl Els. (2008) Management of Tobacco Addiction in Patients

with Mental Illness. Smoking Cessation Rounds web presentation

www.smokingcessationrounds.ca/cgi-bin/templates/body/accueil.cfm

Els, Charl and Diane Kunyk. (2008) Management of Tobacco Addiction in

Patients with Mental Illness. Smoking Cessation Rounds publication.

Dr. Andrew Pipe is a very well respected expert in the field of smoking cessation. He has been involved

in a lot of work with the issues of cessation and addiction as well as cessation and mental illness as well

as much advocacy work. Dr. Char Els has been very active in the cessation effort for those living with

mental illness.

This presentation and document provide very up-to-date information on what doctors can be using as

approaches and support medications for those living with mental illness.

It also makes recommendations for special considerations for supporting cessation efforts with people

having specific mental illnesses.

The table with the Top 10 myths about tobacco cessation in the mentally ill provides good responses

for those that would obstruct this approach.

Johnson, Joy L., et. al. (2006) Tobacco Reduction in the context of Mental Illness

and Addictions - A Review of the Evidence. Provincial Health Services Authority,

BC.

This is one of a very few documents that focus on Canadian information. It does a good job of providing

an overview of:

The prevalence of tobacco use among people with mental illness or addictions,

The factors associated with tobacco use by people with mental illness or addictions,

The effects of smoking cessation for people with mental illness or addictions,

The challenges of smoking cessation for people with mental illness or addictions, and

Strategies and approaches to facilitate smoking cessation by people with mental illness or

addictions.

Based on the evidence reviewed, the authors strongly endorsed:

Tobacco treatment for persons with mental illness or addictions should be integrated into

existing mental health and addictions services.

Counsellors and health care providers need support and training to incorporate brief

interventions into their practices,

Nicotine replacement therapy should be provided to all individuals with mental illness or

addictions who are wanting to quit or reduce their smoking,

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Individuals who are taking anti-psychotic medications and quit smoking should have their smoke

free spaces support and encourage individuals with mental illness and addictions to remain

smoke free.

This information would be good background reading for program facilitators. The section on The Culture

of Mental Health and Addictions Services is good information to know before approaching the front line

workers.

A word of caution from V. Bryanton: in my investigation I tracked back to a few source documents used

in this PHSA Review. I found the evidence cited, or interpretation by the Review authors, to be

somewhat weak or questionable. Their interpretation alone should not necessarily be accepted as strong

evidence. My recommendation of the above points for the PEI Lung Association project is supported by

additional evidence from other articles/sources.

McNeill, Ann. (2001) Smoking and mental health - a review of the literature.

SmokeFree London Programme. London, UK.

McNeill’s review found that there is lots of evidence to suggest that smokers living with mental illness

are motivated to quit smoking. She also interviewed some research authors and further suggests that

teaching frontline workers to ask about smoking behaviour (at every visit) is very important as is not

trying to address cessation during acute phases of the mental illness.

The section on pharmacotherapies is older but is a good starting point when addressing concerns that

may crop up about the use of cessation aids with this population.

MIND - National Association for Mental Health. (2008) Smoking, giving up and

mental health - fact sheet. London, England. Webseries: http://www.mind.org.uk/Information/Factsheets/Smoking+giving+up+and+mental+

health.htm#_ftn35

This MIND factsheet addresses the smoking cessation issue as a response to smoking bans – which

makes it a somewhat negative approach but it is a good example of plain language writing.

The factsheet also contains keys points that should be understood and addressed in PEI’s project:

Mental health professionals may miss opportunities to offer smoking cessation counselling

to clients.

A UK survey asking about smoking habits and attitudes found that 60 per cent of mental

health workers believed that staff should be allowed to smoke with patients; 54 per cent

believed that it plays a valuable role in creating therapeutic relationships.

There is a perception amongst mental health workers that giving up smoking increases

psychotic symptoms and increases the risk of violent behaviour. However, a literature

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review has shown that smoking bans in mental health settings show 'no major longstanding

untoward effects in terms of behavioural indicators of unrest or compliance.' Another study

shows no significant increase or decrease of the symptoms of psychiatric disorders of

patients during hospitalisation in hospitals with a smoking ban.

U.S. Department of Health and Human Services. (2008) AHCPR Supported Clinical

Practice Guidelines Treating Tobacco Use and Dependence: 2008 Update.

Agency for Healthcare Research and Quality (AHRQ). Maryland, USA.

These comprehensive US Guidelines are very well written with clear evidence support. Where there is

not a Canadian Guideline, this set of guidelines has covered quite a territory and could be relied on to

answer detailed questions that may arise as the PEI Project progresses.

U.S. Department of Health and Human Services. (2008) Effectiveness of, and

estimated abstinence rates for, various intensity levels of session length. AHCPR

Supported Clinical Practice Guidelines Treating Tobacco Use and Dependence:

2008 Update. Agency for Healthcare Research and Quality (AHRQ). Maryland,

USA. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.table.29542

The meta-analysis review regarding intensity of intervention showed that a high intensity intervention

(one where sessions are more than 10 minutes each, works best but even a 3 minute conversation can

have a real impact):

Table: Meta-analysis (2000): Effectiveness of and estimated abstinence rates for

various intensity levels of session length (n = 43 studies)

Level of contact Number of

arms

Estimated

odds ratio

(95% C.I.)

Estimated abstinence

rate (95% C.I.)

No contact 30 1.0 10.9

Minimal counseling (< 3 minutes) 19 1.3 (1.01–1.6) 13.4 (10.9–16.1)

Low-intensity counseling (3–10 minutes) 16 1.6 (1.2–2.0) 16.0 (12.8–19.2)

Higher intensity counseling (> 10 minutes) 55 2.3 (2.0–2.7) 22.1 (19.4–24.7)

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U.S. Department of Health and Human Services. (2008) Components of an

intensive tobacco dependence intervention. AHCPR Supported Clinical Practice

Guidelines Treating Tobacco Use and Dependence: 2008 Update. Agency for

Healthcare Research and Quality (AHRQ). Maryland, USA.

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.table.29469

In the absence of Canadian Guidelines in this area, information on the components of an “intensive

program” is recommended for not only heavily addicted smokers but those who might need extra care.

Components of an intensive tobacco dependence intervention

Assessment Assessments should determine whether tobacco users are willing to make a quit attempt using an

intensive treatment program. Other assessments can provide information useful in counselling (e.g.,

stress level, dependence; see Chapter 6A, Specialized Assessment).

Program

clinicians

Multiple types of clinicians are effective and should be used. One counselling strategy would be to

have a medical/health care clinician deliver a strong message to quit and information about health

risks and benefits, and recommend and prescribe medications recommended in this Guideline

update. Nonmedical clinicians could then deliver additional counselling interventions.

Program

intensity

There is evidence of a strong dose-response relation; therefore, when possible, the intensity of the

program should be:

Session length - longer than 10 minutes

Number of sessions - 4 or more

Program

format

Either individual or group counselling may be used. Telephone counselling also is effective and

can supplement treatments provided in the clinical setting. Use of self-help materials and cessation

Web sites is optional. Follow-up interventions should be scheduled (see Chapter 6B).

Type of

counselling

and

behavioural

therapies

Counselling should include practical counselling (problem solving/skills training) (see Table 6.19)

and intra-treatment social support (see Table 6.20).

Medication

Vicki’s note:

Use Canadian

guidelines

Every smoker should be offered medications endorsed in this Guideline, except when

contraindicated or for specific populations for which there is insufficient evidence of effectiveness

(i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents; see Table 3.2 for

clinical guidelines and Tables 3.3–3.11 for specific instructions and precautions). The clinician

should explain how medications increase smoking cessation success and reduce withdrawal

symptoms. The first-line medications include: bupropion SR, nicotine gum, nicotine inhaler,

nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline. Certain combinations of

cessation medications also are effective. Combining counseling and medication increases

abstinence rates.

Population Intensive intervention programs may be used with all tobacco users willing to participate in such

efforts.

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U.S. Department of Health and Human Services. (2008) Effectiveness of and

estimated abstinence rates for various intensity levels of session length. AHCPR

Supported Clinical Practice Guidelines Treating Tobacco Use and Dependence:

2008 Update. Agency for Healthcare Research and Quality (AHRQ). Maryland,

USA. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.table.29544

The number of interventions required to have an impact on cessation effort was reviewed.

Table: Meta-analysis (2000): Effectiveness of and estimated abstinence rates for number of person-to-

person treatment sessions (n = 46 studies)

Number of

sessions

Number of arms Estimated odds ratio (95%

C.I.)

Estimated abstinence rate (95%

C.I.)

0–1 session 43 1.0 12.4

2–3 sessions 17 1.4 (1.1–1.7) 16.3 (13.7–19.0)

4–8 sessions 23 1.9 (1.6–2.2) 20.9 (18.1–23.6)

> 8 sessions 51 2.3 (2.1–3.0) 24.7 (21.0–28.4)

National Association of State Mental Health Program Directors. (2007) Tobacco

Free Living in Psychiatric Settings - a best-practices toolkit promoting wellness

and recovery. Alexandria, VA, USA. www.nasmhpd.org

This document is a good source of information for the long-term care facilities for mental health

patients. Although this group is not a focus of the present Project, it would be good to have this

information if it is requested or if there is a need to respond or be seen to be supportive to this group.

Victorian Smoking and Health Program. (2003) Mental Illness and Smoking

Cessation Australia background brief. Victoria, Australia.

If individuals with schizophrenia are to be included in cessation efforts, this background brief provides

important points that should be addressed or at least accounted for in the Evaluation process.

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Group Programs for Mental Health Clients

Breathing Easy Smoking Cessation- British Columbia Breathing Easy is an education and support program designed to help

people with a psychiatric diagnosis face the extra challenges of quitting

smoking. Seed funding through Health Canada, from 2003 to 2006, allowed

the Canadian Mental Health Association’s Simon Fraser Branch (CMHA-SF)

to develop a comprehensive smoking cessation program for people with

mental illness.

The program combines nicotine replacement therapies with cognitive-

behavioural and psychosocial approaches to quitting smoking. It was

formulated from existing information in the public domain, including work

done by the Canadian Cancer Society and information supplied by Dr.

Debbie Thompson of Surrey North Mental Health Centre on the effect of

nicotine on the brain and interactions with pharmaceutical drugs, as well as

research on social and healthy lifestyle alternatives to smoking.

From January to June 2006, 113 consumers—69 female and 44 male—

participated in the Breathing Easy program. Each participant attended three

or more sessions of the 12-week smoking cessation program. People who

registered for this program but attended two or fewer of the sessions were

assigned to a control group for comparison.

BC Location Number of people in group

Number quit

%

quit

% reduction in

cigarettes smoked by

program completion

New Westminster

21

6

28.6

-37.8

Burnaby

13

4

30.1

-58.2

Tn-Cities

19

5

26.3

-42.0

Maple Ridge

10

0

0

-23.9

Surrey

12

3

25.0

-46.7

Langley

11

3

27.0

-42.5

Mission

7

2

28.5

-74.4

Breathing Easy

As of September 3, 2008 -

After being forwarded several

times, Kay Johnson contacted

me what was being requested

and I responded.

Contact:

Kay Johnson, MA RN

Executive Director

Canadian Mental Health

Association - Simon Fraser

Branch

604-516-8080

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BC Location Number of people in group

Number quit

%

quit

% reduction in

cigarettes smoked by

program completion

Abbotsford 20 3 15.0 -16.9

All groups

113

29

25.7

-40.0

Control Group 22 0 0 +37.0

TEACH

This specialized course allows participants to increase their knowledge about the detection and

treatment of people with concurrent nicotine dependence and mental health and/or addictive

disorders.

Intensive program would rely on attending lengthy training program in Toronto

Ongoing expenses would be a problem - online pre-requisite is free through OTRU, 3 day core

course = $1200, 2 day specialty course costs unknown, but likely at least $800; plus travel and

accommodations for minimum 5 days

Training might be considered for Facilitator Trainer but there is an acceptance process as well

Both Core and Specialty courses are being offered in October 2008 (registration deadline: Aug

29, 2008) and January 2009 (registration deadline: not given but likely end November 2008)

This program is primarily meant to train individual cessation counsellors.

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Training Programs for Frontline Workers

QUIT® Training Courses for Health Professionals

QUIT® is a not-for-profit group in England. The information they have

created for training professionals might be ideal for working with front

line mental health workers.

QUIT® offers trainings in the following relevant areas:

Introduction To Motivational Interviewing - The aim of the training is to

develop understanding and awareness, extend knowledge and increase

the skills needed to encourage patients to consider behaviour change.

We cover topics such as development of motivational interviewing;

motivation as a vehicle for change; components of change: ready willing

& able; empathy, self-efficacy, ambivalence, resistance & discrepancy;

and interaction, open-questions & effective listening. There will be

plenty of opportunities for skills practice. The training is suitable for

health care professionals wanting a basic introduction to motivational

interviewing.

QUIT Mental Health and Smoking Course - At any one time 1 in 6 people

of working age will have a mental health problem, most often anxiety or

depression. 1 person in 250 will have a psychotic illness such as

schizophrenia or bipolar affective disorder. This course is aimed at

smoking cessation advisors and support workers who find themselves

working with clients with mental health issues or who may be invited to

do smoking cessation work in mental health settings. The course will

include information and discussion on the issues involved in mental health and how these impact on

smoking cessation work.

Breaking the Smoking Depression Cycle - Many depressive smokers self-medicate their depression with

nicotine, and research shows that on quitting smoking they may become increasingly prone to further

depression, and relapse. The one-day training course helps Health Professionals to understand and

identify the smoking depression cycle, as well as giving ideas for working with it.

Solving Smoking Challenges - This hands on one-day workshop explores everyday challenges and

creates practical solutions for smoking cessation professionals. We investigate topics such as working

with challenging behaviours, improving client motivation, working within tough budgets and targets,

and discussing individual smoking cessation problems. We will work through your issues and together

develop solutions based on the groups shared experiences and current research evidence.

QUIT

As of September 2, 2008 – we

are still awaiting a response on

requests for information

regarding success and

willingness to share

programming information with

PEI Lung Association.

Contact information:

Paul Rossiter

Training and Corporate Health

Manager

QUIT

211 Old Street

London

EC1V 9NR

Tel: 020 7251 1551

Fax: 020 7251 1661

Email: p.rossiter@quit.org.uk

Web: www.quit.org.uk

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Recommendations The following recommendations are not meant to be prescriptive but are intended to help focus the

project planning process and point to areas of likely success. What must be added into the mix is the

skills of the coordinator, the facilitators and facilitator trainer, the willingness of the system to support

intervention and the timing of other issues affecting these groups.

Target Group Considerations Mental Health Status Not Necessarily Critical Factor for Success

Even after adjustment for age, sex, education, income, depression scores, and smoking restrictions at

home and work, smokers with moderate levels of dependence were least likely to have quit.

Assessing vulnerability to depressions

From: Smoking Cessation Guidelines for Australian General Practice 2004

Smokers with a previous depressive history have a 20-30% rate of recurrence of their depression

on smoking cessation, are at increased risk of problems related to smoking and have more

difficulty in quitting. The period of vulnerability to a new depressive episode appears to vary from

a few weeks to several months after cessation. There is evidence that both bupropion and

nortriptyline are equally effective in smokers both with and without a history of depression. An

important issue in smokers with depression is that bupropion can interact with a number of

antidepressant medicines by lowering the seizure threshold or through other mechanisms.

Caution is needed if there is concomitant use of bupropion with drugs metabolised by CYP2D6

isoenzyme (e.g. tricyclic antidepressants and selective serotonin reuptake inhibitors). If these

drugs are initiated while a patient is taking bupropion then it should be at the lower end of the

dosage range. In the more common situation that bupropion is initiated for a patient already

taking such antidepressants then the dose of tricyclic or SSRI may need to be decreased.

Bupropion should not be used in patients taking monoamine oxidase inhibitors including

moclobemide. A 14 day washout is recommended between completing MAOIs and starting

bupropion.

Schizophrenia

Schizophrenia affects about 1% of the population. Consider delaying inclusion of those people with

schizophrenia for the initial years. There may be more supports specific to this group that would be

better served after the base program is developed.

Strasser, Katherine. (2001) Smoking Reduction and Cessation for people with Schizophrenia -

guidelines for GPs. SANE Australia and the University of Melbourne and endorsed by the Royal

Australian College of General Practitioners and the Royal Australian and New Zealand College of

Psychiatrists. Victoria, Australia. - Many people with schizophrenia smoke and smoke heavily, resulting

in significant health and lifestyle problems. Smoking reduction and cessation is complicated because

smoking may alleviate some of their psychiatric symptoms and lessen the side effects of some

antipsychotics.

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J O Goldberg and J Van Exan. (2008) Longitudinal rates of smoking in a schizophrenia sample. Tob.

Control 17;271-275. The findings from this study suggest that it is possible to obtain reduced smoking

prevalence over time in a selected schizophrenia outpatient sample, though further research is required

to better understand the factors related to quitting smoking in individuals with schizophrenia.

Pharmacotherapy

There is a lot of evidence that cessation support (patch, gum, Zyban, Wellbutrin) can be use safely with

this population. Physicians should not be reluctant to address adding cessation support medications

when a patient wants to quit smoking as the act of quitting alone changes body chemistry significantly

enough to warrant alterations in psychoactive drugs used in treating their mental illness.

Information on the use of pharmacotherapy is an important part of this project and should be created

for frontline workers as well as participants. Before finalizing information on the use of

pharmacotherapy with this population, Canadian guidelines should be consulted.

Also, given recent evidence that the newest support medication – Champix – has been associated with

serious neuropsychiatric symptoms, doctors would need to give this support serious consideration

before issuing a prescription for the drug.

Special Messaging

Most of the evidence suggests that those living with mental illness do not “see” themselves in

traditional smoking cessation program advertising. In the PEI Project’s attempt to alter advertising to

draw more people to existing programs, very little changes to materials may be required.

Extra information for those living with mental illness is covered nicely by SANE when it gives reasons to

quit like:

People who cut down or quit will have more money to spend on enjoyable things like going to

the movies as well as essentials like paying the rent or buying food.

Diseases caused by smoking are the second largest killer of people who have a mental illness.

People who cut down or quit smoking may have their dose of anti - psychotic medication

reduced.

People who change their smoking habits get a real boost in their confidence and feel a great

sense of achievement.

(SANE Australia. (2005). Smoking and Mental Illness - SANE Factsheet 16.

http://www.sane.org/information/factsheets/smoking_and_mental_illness.html )

Working with Mental Health Workers Just because a higher percentage of mental health workers are likely to be smokers (when compared to

the general population) it should not be assumed that they are not interested or able to support their

clients in cessation efforts.

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What the Project Coordinator should keep in mind is that these front line workers will need to

understand:

the importance of their role in helping their clients quit smoking (even a 3 minute chat can have

an impact when done regularly)

how smoking cessation improves (not threatens) the well being of those living with mental

illness

how they can support others in quitting smoking even while they are still smoking themselves

how they themselves can quit smoking

Workers may be attracted to a simple approach of offering training on:

The “5 A's” model for treating tobacco use and dependence Ask about tobacco use. Identify and document tobacco use status for every patient at every visit.

Advise to quit. In a clear, strong, and personalized manner, urge every tobacco user to quit.

Assess willingness to make a quit attempt.

Is the tobacco user willing to make a quit attempt at this time?

Assist in quit attempt. For the patient willing to make a quit attempt, offer medication and provide or refer for counselling or additional treatment to help the patient quit. For patients unwilling to quit at the time, provide interventions designed to increase future quit attempts.

Arrange followup. For the patient willing to make a quit attempt, arrange for followup contacts, beginning within the first week after the quit date. For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at next clinic visit.

Program Considerations After a review of the meta-analysis that have been done and based on 18 years experience of tobacco

control (including smoking cessation support) on PEI, I would recommend the following approach to the

group program test.

A program intervention needs to be longer than 10 minutes per session with 4-8 sessions in total.

Although more than 8 sessions is ideal, it is not practical - nor fiscally feasible - on an ongoing basis to

have facilitators available for more than 8 sessions.

Ideally, with this target group, you should aim for 8 sessions as there may be issues of missing meetings

that will need to be absorbed in a longer program.

Evidence supports a total of no more than 90 minutes of intervention time is all that is required (over

the full length of the program) so unlike previous group programs offered on PEI, aim to have each

intervention no more that 10-20 minutes (as evidence also suggests that more than 90 minutes does not

improve outcomes.) The additional minutes an 8 session X 20 minute course would create may be

needed to deal with specific issues for clients around medications and social issues related to living with

mental illness.

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This type of intervention might easily be added to “club” meetings or other events held on a regular

basis.

The effects of “spacing of sessions” have not been analyzed in detail. Previous group cessation

programs on PEI focused on more meetings in the early weeks during planning to quit and during the

initial quit week. This may be the best approach to maintain although if there is an opportunity to test

one “spacing of sessions” approach to another, this should be done consciously (keep data so that the

two approaches can be compared.)

The Canadian Mental Health Association – Simon Fraser Branch (CMHA-SF)’s program Breathe Easy

would appear to be the PEI Lung Association’s best option for group program testing. Despite delays in

getting a response from this group, I would anticipate a positive response to the idea of sharing the

program information and any training materials.