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1Los Angeles County Peer-to-Peer Quit Smoking ProgramAddressing Tobacco Use in Mental Health and Alcohol and Drug Treatment CentersRachel A. Tyree, MPHLos Angeles County Department of Public HealthTobacco Control and Prevention ProgramSeptember 15, 201012

To assist individuals to lead meaningful lives, we need to promote behaviors that lead to health.

-University of Colorado, Denver, Behavioral Health and Wellness Program

23Peer-to-Peer Program OverviewPersons with serious mental illnesses and substance use disorders represent 7.1% of the total U.S. population, but consume 30-44% of all cigarettes smoked (Lasser K et al: JAMA 284:2606-10, 2000).

Persons with serious mental illness live 25 years less than the general population much of this increased mortality is due to smoking (NASMHPD, 2006).

People with mental health illnesses want to quit smoking and want information about cessation services and resources (Morris et al., 2006).

People with mental health illnesses can successfully quit using tobacco (Evans et al., 2005; George et al., 2002).3Peer-to-Peer Program OverviewPersons with Addictions & Mental Illnesses are:

Nicotine dependent at rates 2-3 times higherRepresent over 44% of the U.S. tobacco marketConsume over 34% of all cigarettes smoked

-Lasser K et al: JAMA 284:2606-10, 2000)445Peer-to-Peer Program OverviewPeople with mental health and substance use disorders do have choices when it comes to their health.

What do persons with mental illness need to quit smoking?

a peer advocate maybe somebody thats smoked and quit smoking and they have ideas of how they dealt with stress at that time and how they deal with it now

-Mental Health Consumer Focus Group Participant, Colorado, 2006.56Peer-to-Peer InterventionsPeer-to-Peer Interventions have become a central part of the substance abuse and mental health recovery movement. The Recovery Movement suggests that adjuncts and alternatives to formal treatment, involvement in self-help groups, and social opportunities at local drop-in centers foster empowerment and provide opportunities for a more meaningful life (Forquer & Knight, 2001, p. 25).

Peer-run services can provide a sense of empowerment, and mutual benefit for the peer provider, as well as the recipient.

6CHOICES ProgramConsumers Helping Others Improve their Condition by Ending SmokingStarted in New Jersey, June 2005

Wellness and Recovery Philosophy

Consumer Tobacco AdvocatesMental health consumer trained on tobacco Deliver message to smokers with mental illness that quitting smoking is importantAdvocate for increased tobacco treatment services for mental health consumersWilliams, 2007; www.njchoices.org

7CHOICES started in New Jersey in June 2005. It is a consumer driven program that embodies the philosophies of wellness and recovery. CHOICES utilizes a brief motivational intervention to enhance motivation to quit smoking and drive mental health consumers to cessation resources.

The program employs a core team of Consumer Tobacco Advocates, mental health consumers who are ex-smokers trained on tobacco, the health consequences, and cessation services.

These consumer tobacco advocates also advocate for increased tobacco treatment services, present at health fairs, and other conferences.

7CHOICES ProgramSince Ive started working for CHOICES, it has strengthened my resolve to stay off of tobacco and live a healthy, well-informed lifestyle. CHOICES not only motivates me to live healthier, but also made me realize that I can live up to my full potential and help others in the process.

CHOICES Consumer Tobacco Advocate, New Jersey 2008

8This is a quote from one of the Consumer Tobacco Advocates that really highlights the mutual benefit of the peer-to-peer model.

By helping other people make the decision to quit smoking and make healthy choices, the Consumer Tobacco Advocates strengthen their decision to be smoke-free and live a healthy lifestyle. 8CHOICES ProgramOf the consumers who met with an Advocate for a brief peer-to-peer intervention, 22% reported trying to quit one month after the intervention.

70% of consumers who had not tried to quit significantly reduced their smoking after receiving the peer-to-peer intervention.

70% of consumers surveyed reported that is was a lot easier to talk with an Advocate about their smoking compared to talking with their psychiatrist or mental health provider.

99LA County Peer-to-Peer Quit Smoking ProgramPeer-to-Peer Embedded ModelCreated by the University of Colorado, Denver Behavioral Health and Wellness ProgramRaise awareness through center in-services, lunch and learn, trainingsConduct one-on-one motivational interviewsProvide cessation service referralsConduct an on-site peer support group10Behavioral Health & Wellness Program

After meeting with the CHOICES Program, the University of Colorado, Denver, Behavioral Health and Wellness Program wanted to build upon their successes.

The Peer-to-Peer Tobacco Program was developed based on the experiences of the CHOICES program and with the help of CHOICES Program staff.

The Behavioral Health and Wellness Program partnered with the CHOICES program to develop the Peer-to-Peer Tobacco Program.

Through the Embedded program, trainings are conducted with existing peer advocates and counselors employed or who volunteer in mental health centers, substance use treatment programs, wellness centers, drop-in centers, etc. (rather than a core team of advocates that travel conducting site visits).

Peer Tobacco Advocates through this program work to raise awareness about the issue of tobacco through center activities or other support groups/programs already up-and-running.

They conduct one-on-one motivational interviews and provide cessation service referrals, similar to the CHOICES Program. In addition, because they are located within the center, they also conduct a weekly on-site peer support group. 10Role of the Tobacco Peer SpecialistRuns onsite support groups, conducts one-on-one motivational interviews with consumers, and provides cessation service referrals. Works at a Wellness Center or AOD Treatment Center.

Joins network of other peer advocates and counselors in sharing lessons learned, ideas for recruitment, and participates in monthly TA calls, other workshops, site visits with the LA County Tobacco Control & Prevention Program.11Behavioral Health & Wellness Program

11Peer-to-Peer Program12Homeless/Transitional Living SheltersVeterans AffairsCommunity Health ClinicsOther ResourcesBehavioral Health & Wellness Program

This is the model for implementing the Peer-to-Peer Tobacco Program within Los Angeles County.

Phase 1: Outreach through DMH Wellness Centers and Substance Abuse Control & Prevention Program contracted treatment centers (May 2009 trainings)

Phase 2: External outreach through trained peers and counselors and other contacts (NRT distribution outreach) (Nov Dec 2009 & May 2010 trainings)

In Los Angeles County, we did our initial outreach through the Department of Mental Health Adults Systems of Care to work with peer advocates employed or volunteering at the departments wellness centers. We also recruited peers and substance abuse counselors through Public Healths Substance Abuse Control & Prevention Programs contracted treatment centers. From there, we built upon our growing networks within these two communities to continue recruitment.

12Peer-to-Peer Program13

Spring 2009 Spring 2010:

5 two-day trainings

Nearly 200 peer advocates and substance use counselors trained

30 programs currently implementing program

Behavioral Health & Wellness Program

LA County Tobacco Control & Prevention Program collaborated with the Behavioral Health and Wellness Program to conduct peer advocate trainings adapting CHOICES program for the Embedded Peer-to-Peer Tobacco Program.

13Embedded Program

14Behavioral Health & Wellness Program

Motivational InterventionPeer Support Group14Motivational Intervention30-minute sessionMotivate smokers with mental health/substance use disorders to seek tobacco dependence treatmentProvides brief, personalized feedback about the impact of tobacco useCarbon Monoxide (CO)Money spent on tobacco15Behavioral Health & Wellness Program

1530-Minute SessionObjectives:Interact one-on-one with smoker Educate smoker on health risks of COGive feedback about smokers own CO levelGive feedback on average daily, weekly, monthly, and yearly amount spent on cigarettesConsider how money could be spent16Behavioral Health & Wellness Program

1630-Minute SessionAfterward, smokers should be able to:Know what CO is and why it is dangerousKnow their own CO levelUnderstand that quitting smoking will reduce CO to a safe levelKnow that a pack/day smoker spends $2,000 per year on cigarettesKnow how much $ they will save if they quit17Behavioral Health & Wellness Program

CO HandoutWhat is Carbon Monoxide?Deadly chemical found in cigarette, cigar and pipe smokeOdorless and colorless gasFound in air pollution (small amounts)Takes the place of oxygen in your bloodIncreases risk for heart attacks18Behavioral Health & Wellness Program

18CO ReadingPeer advocates have the smoker breathe through a carbon monoxide monitor to assess CO levels in the lungsGreat motivational toolPeers use it to assess lung health as they cut down on cigarettesDraws attention to the smoking cessation efforts19Behavioral Health & Wellness Program

19Cost of Smoking Handout20

Behavioral Health & Wellness Program

Next steps: Encourage smokers to:-Talk with counselor or therapist-Discuss tobacco treatment medications with doctor, nurse, or psychiatrist-Call the California Smokers Helpline-Attend the peer support group20Peer Support Group

21Behavioral Health & Wellness Program

Peer Support GroupWeekly, 1 hour groupCan be closed or drop-inParticipants may join at any timeParticipants may attend as many sessions as neededSession topics will cycle over a 6-week period22Behavioral Health & Wellness Program

Groups tend to tweak the amount of time needed for each session depending on wellness center schedule, group interest and dynamics.

Other addicts join the group to apply skills learned to other addictions.

Tobacco-free peers stick with the group for continued support and to provide encouragement and a role to other peers trying to quit. 22Peer Support GroupSession A: Healthy BehaviorsSession B: The Truth About TobaccoSession C: Changing BehaviorsSession D: Coping with CravingsSession E: Managing StressSession F: Planning Ahead23Behavioral Health & Wellness Program

23Session A: Healthy Behaviors

24Objectives:

To learn about living a healthy lifestyle

To discover ways to make healthier choices

To learn about the health effects of smoking and of quitting

5 handouts

Behavioral Health & Wellness Program

24Session B: Truth About Tobacco

25Objectives:

To learn about chemicals in cigarette smoke

To review common myths about smoking

To review reasons to keep smoking and reasons to quit smoking

To determine top 5 reasons to quit

3 HandoutsBehavioral Health & Wellness Program

25What is in Cigarette Smoke?

Handout example26Session C: Changing BehaviorsObjectives:To recognize smoking patternsTo discover new behaviors to change current patternsTo discuss activities that do not involve smoking1 handout27Behavioral Health & Wellness Program

27Session D: Coping with CravingsObjectivesTo learn about cravings and determine current craving scoreTo discover new ways to cope with cravingsTo learn about medications that are helpful when quitting smoking4 handouts28Behavioral Health & Wellness Program

Session D Handout example:

1. What is your craving score?2. Why is your craving score high? or low?3. How are you going to manage the craving?4. How are you going to manage the craving for the rest of the day?

Session E: Managing StressObjectives:To learn about stressTo discuss current stress management habitsTo discover new ways to cope with stress3 handouts30Behavioral Health & Wellness Program

Session F: Planning AheadObjectives:To visualize life as a non-smokerTo discuss potential relapse situationsTo practice preventing relapse and saying no31Behavioral Health & Wellness Program

Peer-to-Peer Program116 peer advocates and substance use counselors trainedNearly 100 providers and clinicians trained with the Ask, Advise, Refer interventionProgram up-and-running in 29 centers/clinicsPartners: Smoking Cessation Leadership Center, Veterans Affairs, Coalition to End Hunger and HomelessnessCurrently conducting impact evaluation study32Behavioral Health & Wellness Program

32LA County ProgramsClinica Monsenor Oscar RomeroDivine Healthcare Services, Inc.Trinity Plus HealthcareNational Council on Alcoholism & Drug Dependence: PomonaB.R.I.D.G.E.S. Project Independence Wellness CenterLong Beach MH Wellness CenterRio Hondo MH Wellness CenterSan Fernando MH Wellness CenterENKI Health ServicesPhoenix HouseSocial Model Recovery Systems

Pacific ClinicsAction Rehabilitation CenterChabad Residential Treatment CenterBACUP Life CenterExodus Recovery, Inc.Harbor UCLA MH Wellness CenterHollywood Wellness CenterNortheast MH Wellness CenterSouth Bay Wellness CenterWest Central Mental Health CenterS.H.A.R.E.! Self HelpDivine Healthcare ServicesVeterans Affairs West LA, Downtown LA & East LA WB Community Learning CenterSustainability:

-Train-the-Trainer program-Monthly TA conference calls-Spanish translation of group session handouts-Web forum-Email listserves-Networking

33Interventions for Tobacco Use34

University of Colorado, Denver, Behavioral Health and Wellness Program:http://www.bhwellness.org/?page_id=7334California Smokers Helpline1-800-NO-BUTTSFree statewide tobacco cessation programScientifically proven to be effectiveAll services available by telephoneIn operation since 1992Adults, teens, pregnant women and proxyMultiple languages

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Funded by tobacco taxes Propositions 99 & 10

35California Smokers HelplineEnglish1-800-NO-BUTTS (1-800-662-8887)Cantonese1-800-838-8917Korean1-800-556-5564Mandarin1-800-838-8917Spanish1-800-45-NO-FUME (1-800-456-6386)Vietnamese1-800-778-8440

3636Elearning - Online CME

37 Online CME (1 credit)Ask, Advise, Refer interventionNicotine replacement therapieswww.publichealth.lacounty.gov Rx for Prevention under Publications and Reports

Upcoming:Online CME for mental health providers and clinicians with the Center for Tobacco Cessation

LA County Department of Public Health E-learning module37Project TRUSTLA County Tobacco Control & Prevention Program received $16 million in economic stimulus dollars for policy, environment, and systems-level change

Mini-Grant ProgramUp to $5,000 for social services agencies100% smoke-free environment policiesImplement smoking cessation programs for staff and consumers/clientsFirst wave of recipients: September 201038Project TRUST: Tobacco Reduction Using effective Strategies and Teamwork38LA Pioneers in Tobacco ControlThe Alcoholism Center for WomenUnited American Indian Involvement, Inc. Veterans Health Association, LA Ambulatory Care CenterCri-Help, Inc. WB Community Learning CenterPhoenix House of Los AngelesPhoenix House of CaliforniaThe Walls Las Memorias ProjectThe Lavelle CenterEpidarurus Amity FoundationChabad Residential Treatment CenterAsian Youth CenterMission City Community NetworkBRIDGESGateways Hospital and Mental Health CenterThe Saban Free ClinicValley Community ClinicPathways to Your FutureTarzana Treatment CenterNCADD South BayNortheast Valley Health CorporationHouse of Hope FoundationAIDS Project Los AngelesLA Biomedical Research InstituteRainbow Bridge Community ServicesDivine Healthcare ServicesHarbor-UCLA Wellness CenterTrinity Plus Healthcare ServicesPenny Lane CentersPasadena Council on Alcoholism & Drug DependenceChild Care Resource CenterSouth Central LA Regional Center for Developmentally Disabled Persons3939Resources

40Quitting Time LA! www.laquits.com

Become An Exhttp://www.becomeanex.org/

ConvierteteEnUnExhttp://es.becomeanex.org/

40Additional ResourcesBehavioral Health and Wellness Program, Mental Health Provider Toolkithttp://www.bhwellness.org/?page_id=73

The Smoking Cessation Leadership Centerhttp://smokingcessationleadership.ucsf.edu/

Centers for Disease Control and Prevention www.cdc.gov/tobacco

U.S. Surgeon General www.surgeongeneral.gov/tobacco/

Partnership to Help Pregnant Smokers Quitwww.helppregnantsmokersquit.org/

Tobacco Cessation Leadership Network www.tcln.org

41TCLN currently has an online CME course that addresses tobacco cessation in mental health and substance use communities (thru December 2010). 41Thank you!Contact Information:

Rachel A. Tyree, MPHProject Director, Tobacco Cessation InitiativesLA County Tobacco Control & Prevention Program(213) 427-4466rtyree@ph.lacounty.govwww.publichealth.lacounty.gov/tobaccowww.laquits.com

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