Faculty Bibliography

OBJECTIVES: We examined tobacco use screening and treatment by US psychiatrists before and after release of the 1996 American Psychiatric Association (APA) nicotine dependence treatment guidelines. METHODS: We used data from the National Ambulatory Medical Care Survey to identify rates of tobacco screening and treatment by psychiatrists before the release of the guidelines (1993-1996) and during 2 postguidelines periods: 2001-2005 and 2006-2010. Multiple logistic regression was used to compare preguidelines and postguidelines rates. RESULTS: Psychiatrists screened for tobacco use during 77% of visits from 1993 to 1996, 69% of visits from 2001 to 2005 (odds ratio [OR] = 0.69; 95% confidence interval [CI] = 0.64, 0.75), and 60% of visits from 2006 to 2010 (OR = 0.46; 95% CI = 0.43, 0.50). Psychiatrists provided cessation counseling to 12% of smokers from 1993 to 1996, 11% from 2001 to 2005 (OR = 0.97; 95% CI = 0.74, 1.26), and 23% from 2006 to 2010 (OR = 2.23; 95% CI = 1.74, 2.86). Psychiatrists prescribed nicotine replacement therapy to fewer than 1% of smokers during all 3 time periods. CONCLUSIONS: Psychiatrists are screening for tobacco use at declining rates, and the proportion of smokers provided with treatment remains low.

BACKGROUND: This paper describes an innovative protocol for a type-II hybrid effectiveness-implementation trial that is evaluating a smoking cessation telephone care coordination program for Veterans Health Administration (VA) mental-health clinic patients. As a hybrid trial, the protocol combines implementation science and clinical trial methods and outcomes that can inform future cessation studies and the implementation of tobacco cessation programs into routine care. The primary objectives of the trial are (1) to evaluate the process of adapting, implementing, and sustaining a smoking cessation telephone care coordination program in VA mental health clinics, (2) to determine the effectiveness of the program in promoting long-term abstinence from smoking among mental health patients, and (3) to compare the effectiveness of telephone counseling delivered by VA staff with that delivered by state quitlines. METHODS/DESIGN: The care coordination program is being implemented at six VA facilities. VA mental health providers refer patients to the program via an electronic medical record consult. Program staff call referred patients to offer enrollment. All patients who enroll receive a self-help booklet, mailed smoking cessation medications, and proactive multi-call telephone counseling. Participants are randomized to receive this counseling from VA staff or their state's quitline. Four primary implementation strategies are being used to optimize program implementation and sustainability: blended facilitation, provider training, informatics support, and provider feedback. A three-phase formative evaluation is being conducted to identify barriers to, and facilitators for, program implementation and sustainability. A mixed-methods approach is being used to collect quantitative clinical effectiveness data (e.g., self-reported abstinence at six months) and both quantitative and qualitative implementation data (e.g., provider referral rates, coded interviews with providers). Summative data will be analyzed using the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework. DISCUSSION: This paper describes the rationale and methods of a trial designed to simultaneously study the clinical effectiveness and implementation of a telephone smoking cessation program for smokers using VA mental health clinics. Such hybrid designs are an important methodological design that can shorten the time between the development of an intervention and its translation into routine clinical care. TRIAL REGISTRATION: ClinicalTrials.gov NCT00724308.

ABSTRACT: BACKGROUND: Hospitalization may be a particularly important time to promote smoking cessation, especially in the immediate post-discharge period. However, there are few studies to date that shed light on the most effective or cost-effective methods to provide post-discharge cessation treatment, especially among low-income populations and those with a heavy burden of mental illness and substance use disorders. METHODS/DESIGN: This randomized trial will compare the effectiveness and cost-effectiveness of two approaches to smoking cessation treatment among patients discharged from two urban public hospitals in New York City. During hospitalization, staff will be prompted to ask about smoking and to offer nicotine replacement therapy (NRT) on admission and at discharge. Subjects will be randomized on discharge to one of two arms: one arm will be proactive multi-session telephone counseling with motivational enhancement delivered by study staff, and the other will be a faxed or online referral to the New York State Quitline. The primary outcome is 30-day point-prevalence abstinence from smoking at 6-month follow-up post-discharge. We will also examine cost-effectiveness from a societal and a payer perspective, as well as explore subgroup analyses related to patient location of hospitalization, race/ethnicity, immigrant status, and inpatient diagnosis. DISCUSSION: This study will explore issues of implementation feasibility in a post-hospitalization patient population, as well as add information about the effectiveness and cost-effectiveness of different strategies for designing smoking cessation programs for hospitalized patients. TRIAL REGISTRATION: Clinicaltrials.gov ID# NCT01363245.

BACKGROUND: Proactive telephone-based smoking cessation counseling is an emerging approach to helping mental health patients quit smoking, and it is unclear whether all patients benefit equally. We examined whether mental health patients enrolled in a telephone smoking cessation program with higher Global Assessment of Functioning (GAF) scores had better quit rates at 6 month follow-up compared to mental health patients with lower GAF scores. METHODS: We analyzed preliminary data from a multi-site VA study implementing a telephone care coordination program for smokers with mental illness. VA providers referred smoking patients to the program via a CPRS consult, and 366 referred patients enrolled in the program. We randomized participants to receive counseling from either a state Quitline or a VA counselor. We collected patient GAF scores through the CPRS system for those enrolled in counseling using the most recent GAF score received prior to their program enrollment date. Based upon the GAF's definition of functionality and of what constituted serious impairment of functioning, we categorized GAF scores above 50 as "high functioning" and scores 50 and below as "low functioning." Patients completed a phone survey at 6 months that assessed their 30-day point prevalence abstinence. RESULTS: GAF scores were available for 103/180 patients who had enrolled in counseling and completed the 6 month follow-up. Of those patients, 70 (68%) had high GAF scores and 33 (32%) had low GAF scores. At 6-month follow-up, 33/103 (32%) had quit smoking. There was no difference in abstinence rates between the high and low functioning GAF groups (33% versus 30%, OR=1.13, 95%CI=0.46-2.75). The GAF score was completed on average 125 days before the smoking cessation referral, and there was no significant difference in the interval between the high GAF and low GAF groups (99 vs. 181 days; p>.05). CONCLUSIONS: The telephone smoking cessation program produced excellent long-term abstinence rates and was equally effective !

BACKGROUND: Providers and patients are encouraged by reduction in the number of cigarettes smoked, but it is unclear this represents a meaningful outcome. A proactive telephone smoking cessation counseling study in smokers with mental illness examined whether a reduction in number of cigarettes smoked per day (CPD) from baseline to 2 months associated with sustained reduction or abstinence at 6 months. METHODS: Participants (421) from a multi-site VA study evaluating telephone care for VA smokers with mental illness received smoking cessation education, were offered cessation medications and received telephone counseling from the VA or State Quitline. Participants completed a structured assessment upon enrollment, and 2 and 6 months postenrollment. Chi-square analyses examined whether persons who were abstinent or had reduced their CPD by at least 50% by 2 months were more likely to be abstinent or have continued their reduction in smoking at 6 months. RESULTS: 104 participants completed baseline, 2 month and 6 month surveys. 49%(50/104) achieved at least a 50% reduction in CPD by 2 months, 44% (22/50) were abstinent. 50% (26/50) of patients who achieved at least 50%reduction in CPDby 2 months remained at the reduced number of CPD or decreased their CPDmore by 6 months. Patients who reduced CPD by 50%by 2 months were more likely to be abstinent at 6 months compared to patients who had not achieved 50% reduction in CPD by 2 months (44% vs. 19%, OR =3.46, 95%CI 1.43-8.38). Patients who were abstinent by 2months weremore likely to be abstinent at 6 months compared to patients who were not abstinent by 2 months (81% vs. 17%, OR=21.9, 95%CI 6.4-74.5). CONCLUSIONS: Data support short-term harm reduction as a model for long-term abstinence in a mental health population. Referral to smoking cessation counseling and initial harm-reduction steps should be encouraged for patients not ready or able to immediately quit. All smokers, no matter their stage of change, should be offered effective cessation trea!

Introduction: State smoking-cessation telephone Quitlines have become an integral part of the United States' public health strategy for helping smokers quit. It is unclear whether these Quitlines meet the needs of smokers with a mental illness, who have unique challenges during the quitting process and may benefit from more intensive treatment. We conducted a needs assessment survey of U.S. state Quitlines (N= 51, including Washington, D.C.) to learn how they work with mentally ill callers. Methods: Quitline representatives were asked whether they have or perform six services chosen to represent basic elements of treatment access, process, and structure for mentally ill smokers. Results: We had a 96 percent response rate to our inquiries. All surveyed Quitlines accept calls from mentally ill smokers, and all either train their counselors in mental health or their counselors have past mental health training. In addition, all Quitlines encourage mentally ill callers to discuss quitting with their usual care provider for safety reasons. However, only eight sun'eyed Quitlines screen callers for mental illness, nine use specific counseling protocols for mentally ill callers, and only three have self-help materials tailored for the mentally ill. Discussion: Future studies are needed to identify the most effective approaches to providing telephone-based care for smokers with mental illness.

Objective: State smoking cessation telephone quitlines have become an integral part of the U.S. public health strategy for helping smokers quit. It is unclear whether these quitlines meet the needs of smokers with a mental illness, who have unique challenges during the quitting process and may benefit from more intensive treatment compared to smokers without mental illness. We conducted a needs assessment survey of U.S. state quitlines (N=51 including Washington DC) to learn how they work with mentally ill callers. Methods: Quitline representatives were asked whether they have, or perform, six services chosen to represent basic elements of treatment access, process and structure for mentally ill smokers. Findings: We had a 96% response rate to our survey. All surveyed quitlines accept calls from mentally ill smokers, and all either train their counsellors in mental health or their counsellors have past mental health training. In addition, all quitlines encourage mentally ill callers to discuss quitting with their regular healthcare providers for safety reasons. However, only eight surveyed quitlines (16%) screen callers for mental illness, few (18%) use specific counselling protocols for mentally ill callers, and even fewer (6%) have self-help materials tailored for the mentally ill. Conclusions: Future studies are needed to analyse these variations in state quitline operations to identify the most effective approaches to providing telephone-based treatment for smokers with mental illness.

Three experiments assessed how speakers avoid linguistically and nonlinguistically ambiguous expressions. Speakers described target objects (a flying mammal, bat) in contexts including foil objects that caused linguistic (a baseball bat) and nonlinguistic (a larger flying mammal) ambiguity. Speakers sometimes avoided linguistic-ambiguity, and they did so equally regardless of whether they also were about to describe foils. This suggests that comprehension processes can sometimes detect linguistic-ambiguity before producing it. However, once produced, speakers consistently avoided using the same linguistically ambiguous expression again for a different meaning. This suggests that production processes can successfully detect linguistic-ambiguity after-the-fact. Speakers almost always avoided nonlinguistic-ambiguity. Thus, production processes are especially sensitive to nonlinguistic- but not linguistic-ambiguity, with the latter avoided consistently only once it is already articulated.