1. A Real World Approach to Treating Tobacco Use in Mental Health Settings Jill Williams, MD Associate Professor of Psychiatry and Director of the Division of Addictions Psychiatry Learning about Healthy Living Manual

2. Disclosures Grant support from NIDA, NIMH, Pfizer Advisory Board Member- Pfizer

3. Objectives 1.Discuss a wellness-based group treatment approach that facilitates the adoption of a tobacco free lifestyle for mental health consumers with different levels of motivation. 2.Identify challenges for group leaders in presenting information to mental health consumers. 3.Describe the use and benefits of a valuable motivational tool – the carbon monoxide (CO) meter. 4.Become familiar with strategies for teaching smokers with mental illness about the consequences of smoking

4. Three Fourths of Smokers have a Past or Present Problem with Lasser et al., 2000; Data from National Comorbidity Study Mental Illness or Addiction

5. Stages of Change Prochaska and DiClemente Precontemplation not thinking of stopping in next 6 months Contemplation thinking of stopping in next 6 months Preparation planning stop in next 1 month Action quit date Maintenance abstinent >6 months

6. Preparation Most smokers enter here SMI Smokers

7. Goals of MI Precontemplation Contemplation Preparation SUCCESS !

8. Language is Important Tobacco Dependence Treatment vs. “Smoking Cessation” “Quitting” “Stop Smoking”

9. Engaging Low Motivated Smokers Half of smokers with SMI have no plans of quitting in next 6 months. Less than 25% planning to quit in the next 30 days Need to increase motivational levels in clients before tobacco treatment can commence Carosella et al., 1999; Addington et al., 1997; Hall et al., 1995; Etter et al., 2004

10. Complete Wellness: Mental and Physical Health Complete Wellness Healthy Food Choices Daily Physical Activity Balancing Relaxation & Stress Addressing Addictive Behaviors Regular Checkups Mental Health & Recovery Plan Wellness & Recovery includes Addressing Tobacco

11. Complete Wellness Approach LAHL developed to help low motivated smokers Mental health settings Group format Education on range of topics –Healthy eating –Increasing activity –Awareness of tobacco addiction

12. Learning About Healthy Living TOBACCO AND YOU Jill Williams, MD Douglas Ziedonis, MD, MPH Nancy Speelman, CSW, CADC, CMS Betty Vreeland, MSN, APRN, NPC, BC Michelle R. Zechner, LSW Raquel Rahim, APRN Erin L. O’Hea, PhD http://rwjms.umdnj.edu/addiction/ AVAILABLE FREE ONLINE http://rwjms.umdnj.edu/addiction/

13. Learning About Healthy Living is a collaborative project between which is funded by the New Jersey Division of Mental Health Services

14. This manual was designed for several reasons: 1. To give information about the relationship of psychiatric symptoms and tobacco use/addiction. 2. To give information about the recovery process from tobacco addiction. 3. To increase motivation about wanting to lead a tobacco-free lifestyle and quit smoking.

15. This manual was designed for several reasons (con’t) 4. To develop skills that will assist in quitting and getting healthy. 5. To teach specific relapse skills 6. To use the group format to provide additional support and modeling experiences for the client struggling with a mental illness.

16. Learning About Healthy Living This treatment is designed as two groups. Group I - Learning About Healthy Living Group II - Quitting Smoking It is designed so that consumers can progress from Group I to Group II, when appropriate or desired

17. Facilitator’s Guide Accompanies each Chapter Objectives Suggested Approach Additional Resources/ References Group 1- 20 Sessions Group II- 6 Sessions

19. Group I: Learning About Healthy Living 20 Weeks Educational and Motivational Accepts all smokers with SMI Piloted in outpatients Smoking within the context of Healthy Living (Exercise, stress, & diet) Could change the order of the sessions and some may take longer than 1 session

21. Therapist Style of Delivering Treatment Client Check-in – tobacco and other activities –self-reported cigarettes per day last week & do expired carbon monoxide (if possible) Be supportive, empathic Coach / Facilitator –Involve everyone in process –Ask them about their opinions / thoughts on the topics –Be educational and motivational Provide repetition and assess comprehension

50. 91% Consumer Interest in Group Rated as Excellent or Very good Williams, J.M., et al. A wellness approach to addressing tobacco in mental health settings: Learning about Healthy Living. Am J Psychiatr Rehabil, 12:352-369, 2009

51. 89% Consumer Level of Participation in Group Rated as Excellent or Very good Williams, J.M., et al. A wellness approach to addressing tobacco in mental health settings: Learning about Healthy Living. Am J Psychiatr Rehabil, 12:352-369, 2009

52. LAHL in Psychosocial Rehab Clubhouses (NC) Staff and member surveys Of the 271 participants (9 programs) 58% completed surveys Tested well: feasible and well-received Group facilitators non-clinicians Staff had been concerned about the viability of the program at its start, but were later surprised, The curriculum had provided a sense of camaraderie among members and generated energy for other healthy changes in the clubhouse Lee et al. BMC Public Health. 2011 Sep 14;11:702.

53. Conclusions LAHL is feasible and well-received in MH settings Increasing consumers readiness to change tobacco use behavior Easy to implement with limited training Let us know your experiences with it jill.williams@umdnj.edu