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
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

Page | 2
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.

Page | 3
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.}

Page | 4
  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,

Page | 5
  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

Page | 6
 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 Estimated Estimated abstinence

arms odds ratio rate (95% C.I.)
(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)

Page | 7
  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 Multiple types of clinicians are effective and should be used. One counselling strategy would be to
clinicians 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 There is evidence of a strong dose-response relation; therefore, when possible, the intensity of the
intensity program should be:
Session length - longer than 10 minutes
Number of sessions - 4 or more

Program Either individual or group counselling may be used. Telephone counselling also is effective and
format 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 should include practical counselling (problem solving/skills training) (see Table 6.19)
counselling and intra-treatment social support (see Table 6.20).
and
behavioural
therapies

Medication Every smoker should be offered medications endorsed in this Guideline, except when
Vicki’s note: contraindicated or for specific populations for which there is insufficient evidence of effectiveness
Use Canadian (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents; see Table 3.2 for
guidelines 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.

Page | 8
  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 Number of arms Estimated odds ratio (95% Estimated abstinence rate (95%
sessions C.I.) 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.

Page | 9
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 Breathing Easy
smoking. Seed funding through Health Canada, from 2003 to 2006, allowed
As of September 3, 2008 -
the Canadian Mental Health Association’s Simon Fraser Branch (CMHA-SF)
After being forwarded several
to develop a comprehensive smoking cessation program for people with
times, Kay Johnson contacted
mental illness.
me what was being requested
The program combines nicotine replacement therapies with cognitive- and I responded.
behavioural and psychosocial approaches to quitting smoking. It was
Contact:
formulated from existing information in the public domain, including work
done by the Canadian Cancer Society and information supplied by Dr. Kay Johnson, MA RN
Debbie Thompson of Surrey North Mental Health Centre on the effect of Executive Director
nicotine on the brain and interactions with pharmaceutical drugs, as well as Canadian Mental Health
research on social and healthy lifestyle alternatives to smoking. Association - Simon Fraser
Branch
From January to June 2006, 113 consumers—69 female and 44 male—
604-516-8080
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 Number % % reduction in

group quit quit 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

Page | 10
BC Location Number of people in Number % % reduction in
group quit quit 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.

Page | 11
Training Programs for Frontline Workers

QUIT® Training Courses for Health Professionals

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

QUIT
created for training professionals might be ideal for working with front
line mental health workers. As of September 2, 2008 – we
are still awaiting a response on
QUIT® offers trainings in the following relevant areas:
requests for information
Introduction To Motivational Interviewing - The aim of the training is to regarding success and
develop understanding and awareness, extend knowledge and increase willingness to share
the skills needed to encourage patients to consider behaviour change. programming information with
We cover topics such as development of motivational interviewing; PEI Lung Association.
motivation as a vehicle for change; components of change: ready willing
Contact information:
& able; empathy, self-efficacy, ambivalence, resistance & discrepancy;
Paul Rossiter
and interaction, open-questions & effective listening. There will be
Training and Corporate Health
plenty of opportunities for skills practice. The training is suitable for
Manager
health care professionals wanting a basic introduction to motivational
QUIT
interviewing.
211 Old Street
QUIT Mental Health and Smoking Course - At any one time 1 in 6 people London
of working age will have a mental health problem, most often anxiety or EC1V 9NR
depression. 1 person in 250 will have a psychotic illness such as Tel: 020 7251 1551
schizophrenia or bipolar affective disorder. This course is aimed at Fax: 020 7251 1661
smoking cessation advisors and support workers who find themselves Email: p.rossiter@quit.org.uk
working with clients with mental health issues or who may be invited to Web: www.quit.org.uk
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.

Page | 12
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.

Page | 13
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.

Page | 14
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 Is the tobacco user willing to make a quit attempt at this time?
make a quit attempt.
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.

Page | 15
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.

Page | 16