Training Mental Health Professionals to Treat Tobacco Dependence

To the Editor: Compared with the general population, individuals with serious mental illness are heavier smokers and have higher levels of nicotine dependence and higher relapse rates after quitting (1). Smoking rates among adults in New York City declined 31% between 2002 (21.5%) and 2011 (14.8%) (2); yet rates among persons with serious mental illness remain high. A 2010 New York City Department of Health and Mental Hygiene (DOHMH) survey of supportive housing program clients, including many with mental illness, found that 66% smoked (DOHMH, unpublished data, 2010). Evidence suggests that training health care professionals on smoking cessation has an impact on patient behavior (3). Thus the Communities Putting Prevention to Work initiative of the Centers for Disease Control and Prevention (4), which was implemented by DOHMH, focused on integrating tobacco dependence treatment into behavioral health services by implementing a train-the-trainer program for clinical and lay staff serving adults with serious mental illness.

Between May 2010 and January 2011, ten train-the-trainer sessions were conducted for 44 assertive community treatment (ACT) teams and 160 supportive housing programs under contract with DOHMH and serving 7,500 clients annually. Duration was 18 hours (over three days). The curriculum focused on increasing understanding of tobacco addiction and its health impacts and training participants in use of quit-smoking medications and provision of cessation counseling based on motivational interviewing techniques. Participants were educated about smoking cessation benefits provided by New York State (NYS) Medicaid, the NYS Smokers’ Quitline, and community-level cessation services. Pairs of participants were expected to train colleagues within four months of their training session.

Evaluation of the initiative was conducted by using Survey Monkey software for baseline and follow-up assessments of ACT team leaders and supportive housing program directors. Results indicated statistically significant improvements among staff in knowledge and attitudes about tobacco dependence treatment, including counseling techniques (67% increase in knowledge among ACT staff and 115% increase among housing program staff) and medications and cessation resources (80% and 29%, respectively, among housing program staff). The proportion of supportive housing programs that provided individual counseling increased significantly by 25%. All ACT teams and 90% of supportive housing programs implemented turnkey trainings, completing most modules.

DOHMH successfully trained hundreds of providers serving thousands of clients with serious mental illness. Program directors and staff from ACT and supportive housing programs reported gains in knowledge and attitudinal changes. The only significant programmatic change reported was an increase in the number of housing programs offering individual counseling; however, this finding was not surprising, because evidence suggests that provider behavior change is more difficult to achieve than changes in awareness and knowledge (5). Research should examine incorporation of tobacco dependence treatment into daily practice by providers and its impact on client smoking rates. Exploration of remote training modalities is also needed.

This program implementation was a successful first step to increasing tobacco dependence treatment for adults with serious mental illness, a population disproportionately affected by tobacco use. We encourage other jurisdictions to explore ways of adapting this program to the needs of their professional communities.