Moderator: Leslie Brenowitz
May 26, 2010
2:00 pm CT

Coordinator: Welcome and thank you for standing by. At this time all participants are on a listen only mode until the question and answer session. Today's conference is being recorded. If you have any objections you may disconnect at this time.

The PowerPoint presentation PDF version, the audio recording of the teleconference and a written transcript will be posted to the SAMHSA 10x10 Campaign Web site at http://www.10x10.samhsa.gov.

Our presentation today will take place during the first hour and will be followed by a 30-minute question and answer session at which time you may press star 1 to ask a question.

I would now like to turn the call over to Leslie Brenowitz. Ma'am you may begin.

Leslie Brenowitz: Thank you and my apologies to everyone for our slightly delayed start. This is the New Frontiers in Smoking Cessation to Support Wellness Among People with Mental Health Problems training teleconference. Today's teleconference is sponsored by the Substance Abuse and Mental Health Services Administration's 10x10 Wellness Campaign.

SAMHSA, as you may know, is the lead federal agency on mental health and substance use and is located in the U.S. Department of Health and Human Services.

The views expressed in the teleconference do not necessarily represent the views, policies and positions of the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Food and Drug Administration or the U.S. Department of Health and Human Services.

My name is Leslie Brenowitz and I will be moderating the teleconference today.

Our first presenter is Dr. Chad Morris who is Associate Professor at the University of Colorado Denver Department of Psychiatry and Director of the Behavioral Health and Wellness Program. Dr. Morris is pursuing research on community based care models as well as tobacco cessation and obesity interventions for people with mental health problems and substance use disorders.

He is the principle investigator of multiple studies exploring the effectiveness of tobacco cessation strategies and he manages Colorado's SAMHSA projects for assistance in transition from homelessness and New Freedom Initiative Grants.

He is past President of the Colorado Psychological Association and a licensed psychologist.

Chad will share with us information about the state of the science on tobacco cessation for people with mental health problems as well as some insight into the potential future of the discipline. Chad?

Chad Morris: Thank you very much and I am going to forward to my slides. You know thanks again for being able to speak to you today about a very critical issue, and obviously by the number of callers that are calling into this I think there's a realization of how important this issue really is.

So really my job today is really to set the kind of a framework, a platform and talk about some of the statistics and the clinical work done today and really set up the two other speakers to talk about some very specific programs. And so where I would like to start is just talking about how alarming this issue really is.

In the United States we know that the figures vary but 1 in 4 or 1 in 5 folks at any given point in time have a diagnosable behavioral health disorder during the course of any given year. What's really striking now is that for folks that have behavioral health disorders, so we're talking about mental illnesses as well as substance abuse disorders or addictions, these folks are dying 25 years earlier than the general population, that's just startling.

Right now in the U.S. the smoking rate is around 20% or so but what we know about this population is that they are nicotine dependent at two to three times that rate. So, on the low end if you look across studies usually about 40 percent and up of persons with behavioral health disorders and mental health disorders are smoking or nicotine dependent.

And then we also know, and we're going to, I'm going to touch on this again briefly, is that the tobacco market historically has really targeted this population and right now 44 percent of the whole market in the U.S. is made up of persons with mental illnesses and substance abuse disorders.

On this next slide I just wanted to give you a feel for the prevalence rates that we're looking at, and what you see here is a range based on diagnostic category and it's really a range across studies that we know of and every year we're getting more and more information in this regard but you can see that for a diagnosis such as schizophrenia that incredibly high prevalence rates for smoking.

Some studies have showed as high as 90 percent and then you can read that, you know those percentages varied throughout diagnoses but they're very high. I'd also like to point out that when, at the bottom of this slide when you get down to issues such as alcohol abuse, other addictions, again you're getting into an extremely high prevalence rate.

So just once again demonstrating what a, what a critical issue this is and it's an issue that really cuts across disparity groups and across our populations in general.

Now, you know, it's good to look at and speak briefly about barriers and vulnerabilities. And you know, when we're doing this work and we go out and we say we would like to help the folks, this population quit or reduce their smoking there's a lot of questions that naturally arise, and some of these are valid and some of them aren't valid.

And so I think that for a lot of you, and when we go out and we talk to folks there's people talk a lot about the biological predispositions that folks have and what we hear from providers specifically is that we always learn that smoking is actually good for these folks, it has positive effects in concentration and in attention and so forth.

And so that is indeed the case that you know there is some, you know people wouldn't be smoking if there wasn't a benefit to it and there are some different benefits for this population as opposed to the general population, and there's been a lot of research done on this.

The issue is that yes, smoking does help folks attend and concentrate but if you look at, you know, the folks outside of say a community mental health center you're not seeing them smoke one cigarette right, you are seeing them chain smoke. And that's because these effects only last for about five minutes at a time.

And so our whole push here is that kind of undoing that myth that yes, you know there are some benefits to tobacco use but this is also killing these folks so we have to come up with some more appropriate coping strategies. There's systemic hurdles, you know historically smoking in behavioral health settings has been extremely condoned.

In fact, a lot of the consumers and clients that we've talked to, they didn't start smoking until they were actually in institutional settings or in community-based programs and in addition a lot, so the you know, promoted as far as, you know, token economies, things of that nature, so reinforcement around smoking breaks, but also these organizations were actually making quite a bit of money on smoking by selling cigarettes.

We started on the next point talking about some of the provider beliefs, you know around the fact that these folks need to smoke to help their symptoms. But there's a few other myths that are very prevalent, one is that these folks can't quit smoking, another one is they don't want to quit smoking.

So we're going to present a little evidence disproving that and you know, one of the big ones is, and you can do your own naturalistic studies, go ask folks do they want to quit smoking and we've done this in multiple states. And what you're going to find is that the motivation that these individuals have is the same and often greater than the general population for quitting smoking. And what they'll tell you is that they've never been afforded the same opportunities to quit smoking as the general population.

On the psychological and social factors what we're talking about there is that really you know, socially you know a lot of the social groups and so forth and the being the in crowd involves smoking, and so really we're working to change that, that culture if you will both at a pure level and a provider level.

And then I mentioned that the tobacco industry targeting and there's the next slide that, actually I believe it's after this, and we'll go back to the previous slide, but the tobacco industry is targeting after the master settlement agreement all the private or secret tobacco industry documents were open to the public.

And so there had been studies done looking at how big tobacco is really targeting these populations and looking really promulgating the message that these folks were less susceptible to the harms of tobacco and needed tobacco as self medication and there's really, I mean one of these projects was called Project Scum.

And it was really, it was a down scale marketing campaign directly targeting lower SES groups and providing, figuring out where these folks were at and providing cigarettes and other issues and blocking any kind of legislation that was coming up.

Now I'm going to go back a slide because we also, you know I mentioned that there are biological predispositions to smoking among schizophrenia, depression, anxiety, bipolar disorder, so there are some differences in treating this population as opposed to others.

And this is just one example of that that providers and consumers clients need to be aware of and that's that tobacco cessation dramatically affects the amount of medication in ones blood stream so that when people quit smoking their levels of many of these medications on this chart dramatically increase and so you might start to see side effects that you didn't see when folks were smoking.

And so this is just an example of how we do, there are differences and we do need to monitor some things like medication levels when we're working with this population.

And then you know looking at the myths again it's becoming very clear that if you do smoking cessation with this population that there seems to be no negative impact on psychiatric symptoms. Past studies have shown historically that if someone had a history of depression you really need to be concerned about a recurrence of depression but more and more evidence is showing that psychiatric symptoms actually get better as people quit smoking and every year more of these studies are coming out.

And then on the substance abuse side it's also good to note that if you do, you know, look at the addiction, primary addiction someone's coming in for, treat that concurrently with tobacco cessation, you're actually going to increase the likelihood of success of treating that other substance. So you know with meta analysis and so forth you're getting about 25 percent better bang for your intervention if you do both of these concurrently.

Now as far as interventions you really do have to hit both sides, you have to hit the physical side, so we're going to talk really briefly about medications, but you also have to hit the behavioral side and this, you know, the 2008 guidelines for tobacco interventions and everything else points to that this combination is the best thing you can do.

Now we know that tobacco cessation works in the general population but then also in this population. So and this is just giving you a sample, you know if you try to quit cold turkey only about four percent of folks are going to be able to quit, but if you're using pharmacotherapy like nicotine replacement therapy, which is the NRT listed there, you're really going to pop up your chances of cessation.

If you add quit line counseling to NRT it's going to get even better and then there's new medications like Varenicline that are showing that you can get a very high cessation rate. And then we also know that if insurance coverage is there that you're, people are going to be much more likely to quit.

This is an example of the studies I'm mentioning in the literature base, and we don't have time to go into this very deeply, but just the fact that among meta analyses that for a serious mental illness like schizophrenia you can get quit rates as high as 35 to 56 percent, it's going to go down a bit over time but still 12 percent at six months is extremely successful. And then you see, you can read for depression it's even higher at 12 months.

So where do we start and what we know is that even if you, you do something as simple as offer advice that you're going to increase the chances of people quitting smoking and it could be as much as two times.

So we're, the foundation of intervening is really around what we call the five A system where it's very simple and it could be as short as 10–15 minutes, where you want to ask folks are they smoking, you want to advise them that it's not good for you. You want to assess their readiness to quit, assist with that quit attempt and that means referring to proper treatments both internally and in the community and then arrange follow-up to see what actually happens.

So it's really this screening assessment and intervention and follow-up. If you don't have time for that then there's a simpler model that we were calling the two As and R model where you ask, you advise and then you refer. So this means you don't have the capacity to internally do the intervention so you refer to an appropriate resource like the Quit Line, wellness group, etc.

There's a lot of tools out there both on the behavioral and medication side that you can use. Everything that works in the general population works in for this population but the intensity and duration of services might be different, so you do have to do some tailoring but it's the same things that work in the general population.

And this is just to give you an example, we talked medications that there are seven FDA approved medications, most of these being nicotine replacement therapy, we haven't had these around too long, you know it's only been since 1984 the most common ones are the nicotine gum and the patch that are over the counter, the others you need prescriptions for and then there's two medications, Buproprion and Varenicline that we mentioned that are very useful as well.

Buproprion's interesting because you can use it both for depression and for smoking cessation. And so I'd like to, just because we got a later start too, I'd like to end there in setting this base of just turning this over to (Marlene) at this time.

Leslie Brenowitz: Thanks. This is Leslie Brenowitz again. Thank you Chad so much for giving us that overview and I'll just reiterate that after we hear from our three speakers we'll open it up for Q&A so and you're also able to submit questions via the live meeting software, up at the top of your screen.

Our next presenter is Dr. Marlene Reil of the New York City Department of Health and Mental Hygiene Office of Consumer Affairs. She was the developer of the smoking cessation action kit and detailing campaign, a public health campaign modeled after pharmaceutical industry strategies that she will share with us today.

She also was one of the creators and implementers or the Mind Your Health Peer Wellness and Health Coach training program and has presented widely on smoking cessation and co-occurring mental health and substance use disorders.

She is a psychotherapist and addictions counselor at the Metropolitan Center for Mental Health in New York City. Marlene will discuss the implementation of and lessons learned from New York City's provider detailing campaign along with some other New York City based tobacco and health intervention. Marlene?

Marlene Reil: Thanks so much Leslie and thank you all for phoning in and going online and participating in this Webinar, it's very exciting to see the level of interest and the enthusiasm about tobacco cessation for mental health providers for mental health community. So it's really exciting to see that the culture is shifting and we can see it just in the number of attendees in today's call. So as Leslie described I'm going to talk about what public health detailing is, how it's done in the medical community and then how we altered this method to work with the behavioral health providers. And I'll talk a little bit about how we rolled out the campaign, what we learned and also I'm going to talk a little bit about the New York State Medicaid benefits just to give you a sense of the insurance coverage that Chad was talking about.

And finally I'll introduce our latest project, the Mind Your Health Peer Coaching program.

So first of all what is public health detailing? We began it about seven years ago and as Leslie said it's modeled after a pharmaceutical sales approach but instead of creating pharmaceuticals we create action kits that include clinical tools and resources that promote good health and evidence-based healthcare interventions.

Representatives of the New York City Department of Health and Mental Hygiene will go out to primary care and other practices in the five burrows and make brief visits. These brief visits brief medical practitioners about the importance of a particular health issue like hypertension or adult obesity or diabetes.

They'll walk through the elements of the kit, which can include clinical tools, provider resources, patient resources and educational information and that may become a resource that the medical practitioner comes to know and trust.

So this was our first detailing campaign for the mental health provider community. We visited over 400, four field staff visited over 400 mental health outpatient, continuing day treatment centers, (ACT) team, partial hospitalization programs and comprehensive psychiatric emergency programs.

So just want to reiterate that that was four people in 40 days in 400 sites. These first visits occurred in January and February of 2009 and we followed up in July and August about six months later.

So we developed key recommendations for all of our campaigns. These are the main points that are consistently reinforced by every representative at every site. Tools are provided in the kits that help address, that help our providers to address and implement each key recommendation.

So the first one was to assess smoking status and readiness to quit at intake and at least every three months thereafter. And at least in New York State the three-month timeline coincides with the treatment plan reviews. They also recommend that they provide smoking cessation medications and treatments to assist people in becoming tobacco free. And in addition to provide education and raise awareness about becoming and remaining tobacco free.

I'm going to talk a little bit about the action kits, that's a graphic of what the action kit looks like and that line down the middle is something that folds out. And these kits include clinical tools, as I said, provider resources, patient education, information about medication, our latest health bulletins and sometimes we give out some incentives, not as cool as the pharmaceutical incentives but sometimes pens and Post-It pads.

So I'm going to go through those elements one by one. So the clinical tools that we include really support the delivery of evidence-based care, and they assist in implementing clinical preventive services and chronic disease management.

We try to make them very simple, time saving elements that they can utilize in their daily practice and we did the same thing here for behavioral health practitioners. So one of the things that we included that isn't on the slide is a flow sheet for preventive care, which can be very helpful for non-medical behavioral health professionals because it includes things about how often to get certain blood levels checked or what BMIs and weights are within normal range.

We also provided a small easel, a little cardboard backed sheet with a smoking questionnaire that has the Heaviness of Smoking index on it. This is a two-item scale that determines one's severity of tobacco dependence. So this is something that could be placed in the waiting room and consumers who are waiting can fill this out and bring it to their mental health provider and talk about it during their visit.

Finally we provided a tobacco dependence treatment plan, which is available on our department's Web site and in the public domain if you'd like to download it. It includes all of the information needed to document tobacco dependence information goals and objectives including the heaviness of smoking index score, one stage of readiness, medications that the consumer may be taking that are affected by smoking and room for goals, objectives and progress.

In terms of provided resources we tend to provide peer reviewed articles and clinical guidelines based on evidence-based care and the graphic you see there is from one of our City Health Information documents, we call them (CHIs). And this one is on treating tobacco addiction. So this (CHI) has been e-mailed and mailed to the medical provider community as well as nurse practitioners, social workers, anyone on our list and they're also available on our Web site.

We want to make sure that the message we're sending to medical providers is the same message that we're sending to behavioral health providers. We also included two important articles that were written by prominent tobacco dependent specialists.

One was about addressing substance use, tobacco use among individuals with mental health or substance use disorders as well as one that details the steps that organizations can take to address tobacco use among their consumers and staff.

We also provide patient education material to help prompt that discussion with the healthcare provider, like I spoke about the heaviness of smoking index on the easel that you might leave in the waiting room. They're targeted to all literacy levels and are available in multiple languages and we provide the key message to consumers and patients.

Now you see that the still smoking cigarettes are eating you alive graphic, that is in line with our, which was the current campaign for the general public. The posters came in two languages in the kit but were also available in other languages if you called in. And like I said, the easel and palm cards were available also.

We also provided materials in the kits where you can order more materials because we realize that these materials aren't going to stay forever and one final thing we included was our health bulletin, which was in use from our current campaign.

So I'm going to talk a moment about the highlights of the campaign. We realized that we had to take a different approach with the mental health provider community. They've never had a detailing visit before and this was a visit from representatives from the Department of Health. We wanted the providers to know that this was an informational visit and not a surprise audit.

So what we did was we sent a letter to the mental health providers to let them know to expect the call from a representative to set up a time to visit with them and we had it coincide with the new year, which was a really wonderful time because we know that's the time where people are making those all important New Year's resolutions.

So in primary care practice oriented detailing eight weeks is usually enough time to provide an initial and a follow-up visit. This wasn't the case for the mental health community, so we planned a subsequent follow-up at six months and gave sites that received a second visit a copy of Smoke Alarm, The Truth About Smoking and Mental Illness in January 2010 for use in their waiting rooms.

This is a wonderful DVD that describes the myths and truths about smoking and mental illness with experts such as (Jill Williams) and member stories. This DVD was created by the Clubhouse of Suffolk.

We also asked follow-up sites to complete a short survey online about their current practices, successes, challenges and needs. So I'm going to talk about what we learned. First of all we learned that we were pretty effective. We did raise awareness and provided the mental health community with tools and resources to address tobacco dependence as mental health consumers.

We realized that their smoking status, assessing that status went up from 21.2 percent to 58 percent at treatment plan review. And the programs that provided smoking cessation education medication and counseling increased from about 35 percent to almost 50 percent.

They also were very willing to use the clinical tools and adopt the key recommendations from the campaign. They also found that the tobacco dependence treatment plan was very useful as a standard protocol when it came to assessing the patient including readiness to quit and the heaviness of smoking index.

While all sites greeted the reps warmly and openly it wasn't always an easy sell. Culture change is occurring and in some places slowly and in other places more quickly. So we're really pleased that we can contribute to that positive change.

Now these lessons learned came as a result of our survey, so these came from the mental health providers themselves, so they found that holding regular group sessions addressing smoking at intake and at reassessments including cessation and treatment planning, educating and counseling clients on the health benefits and the expense of smoking, providing medication, providing one on one counseling, focusing on harm reduction strategies maybe instead of quitting as well as educating their staff and providing a smoke free facility were successful strategies for them.

Some of our barriers, as this was a brand new start in the mental health provider community the reps didn't really know what to expect and some of the mental health sites that we have were larger than originally anticipated.

And what that might mean is that they might've walked into a site that they thought was one site and found out that they had an out-patient clinic but they also had a community day treatment program in the same building and perhaps they also had a partial hospitalization program, so they found that they might show up to do one thing and they needed to visit three separate programs.

So pre-call planning was really important, and this is an element that is not present in the primary care community, the reps would just kind of walk down the street and hit their usual sites and they wouldn't make a call in advance.

We also did a lot of group presentations rather than the one-on-one interactions. You know at CCP offices are normally small with a narrow range of staff, mental health sites are more diverse and have administrators, direct care workers, psychiatrists and office staff. I in fact co-provided two larger training style visits that had 30 to 50 staff members present.

We actually ran out of materials and had to reorder materials for the follow-up, which was a first for the public health detailing office. And instead of visits taking minutes like they planned, visits were taking hours.

So you could really see that this was something that our community really needed and wanted and we were worried that they weren't going to be let in the door but what happened is they were greeted with open arms and once they got someone in they really wanted to learn and talk to them about their experiences.

So in terms of what we learned about future needs it would be great to be able to furnish starter kids as nicotine replacement therapy on site for distribution to consumers. Unfortunately I think financially this can be a difficult thing to do but if nicotine can be placed on site when a consumer shows an interest you can also show them how to use it properly and follow-up with them. And also takes out that step between well you can go to your doctor and get a prescription or go to the store and buy this.

Also our mental healthcare providers we'd love to see them have more campaigns geared towards health issues such as adult obesity and diabetes, HIV testing, and hypertension.

In our survey we asked about what the surveyed sites ranked as the highest priority and they ranked consumer education materials and staff training as their top priorities.

So I just want to talk briefly about the New York State medication, Medicaid Smoking Cessation Policy. It does allow for two courses of smoking cessation therapy per recipient per year, which means a 90-day supply twice a year, and that would be a 90-day supply of any of a combination of the patch, the gum, the vapor inhaler and the puffer but not the lozenges.

So it's important that if you might have in other states a Medicaid benefit for NRT, you also may have Medicaid benefits or Medicare benefits for smoking cessation treatment and visits. So it's important that you investigate that and also speak to the insurance companies that your consumers might be working with or managed care companies to see what can be negotiated.

Finally I just want to talk a bit about where we're going with our own work in tobacco dependence. But that really is to have peer specialists provide some of the health and wellness coaching to the consumers in mental health settings, so we're providing those tools and resources to peer specialists.

So our goal in this program was to improve physical health outcomes for consumers in mental health service settings and we educated 20 peer specialists, I think one of them is on the call today, at least one, on physical health and wellness and we trained them in coaching techniques.

Part of the program was to design health and wellness programming to be implemented in mental health service sites and some focused on creating smoking cessation programming, and some actually quit smoking during the course of the workshop series.

So we are going to do this a second time and round two starts July 13, 2010 for peer specialists currently working in a mental health service setting in New York City. If you'd like to receive an application or details you can contact the person at the e-mail or phone number below.

So I'd like to thank you very much for listening today and I'll be happy to answer questions at the end of the Webinar.

Leslie Brenowitz: Marlene thank you and I think it's so interesting to hear about such an innovative program and the way that it worked in New York City and that there are resources available that people can use and adapt in their setting.

Our final presenter is Marie Verna who's a program support coordinator at the University of Medicine and Dentistry of New Jersey Behavioral Healthcare. Ms. Verna was diagnosed in 1983 with bipolar disorder and since 1997 has devoted her career to improving the lives of people with mental health problems through education and advocacy.

She is the founder of CHOICES, a consumer to consumer tobacco cessation education program that received Mental Health America's Innovation and Creativity in Programming Award. Marie herself is a recipient of the New Jersey Association of State Mental Health Agencies Advocacy Award and she's going to share with us some information today about the CHOICES peer smoking cessation program. Marie?

Marie Verna: Thank you very much. I also would like to reiterate that the number of people on the call is very, very heartening and very, very different from when we started CHOICES in 2002.

I'd like to describe the program that I think has simply changed the conversation in New Jersey about tobacco use among people with mental illness. CHOICES means consumers helping others improve their condition by ending smoking and by condition we mean the overall health and wellness of individuals.

CHOICES was founded by Dr. Jill Williams, a leading researcher here at the Robert Wood Johnson Medical School and myself as the Director of Advocacy.

When we hear the information that Chad and Marlene talk about and that many of us have been tracking and we talk to consumers we learned that none of this information has actually escaped consumers themselves, but they assumed no one was noticing or cared because no one ever talked about their smoking.

So the primary goal of CHOICES from the very beginning was to raise awareness and to create a demand for services, a true demand from a consumer voice. The core philosophy of the program is that when peers communicate with peers when they lead the conversation that is when exponential change happens.

We hire peer educators whom we call consumer tobacco cessation advocates or CTAs. The first message of CHOICES that paying attention to tobacco use is important may seem self evident and we may even think that it's impossible that consumers wouldn't even already know it, but the fact is that the fact that someone's talking about it is the key to CHOICES.

The second message turns out to be vital because in reality seeking tobacco treatment and the impact on their chances of quitting is something that consumers truly don't know about, they truly believe that they should be able to do it cold turkey and they have very little understanding of what treatment is. They're unaware that continually trying to quit cold turkey may set them up for failure, which most consumers don't need any more of.

They also give themselves very little credit for the persistence they've actually demonstrated by trying to quit many times.

Now CHOICES is very, very clear that we are not a treatment service. We are support that consumers have never had. We use techniques of motivational interviewing, intentional support and coaching to meet a person where he or she is, whether they're in an active stage of quitting or not.

Now the advantages of peer educators the increased trust the fact that the experience is shared. Usually much more relaxed and there's no judgment, none whatsoever. The conversations tend to empower consumers and are rated very highly.

When we talk about tobacco it seems that peer education is especially necessary because all of these conditions that have to do with morbidity and mortality, obesity, smoking, are very obvious to consumers and to everyone else in society.

And most consumers are focused on their inability to do much about it so peer educators can remove those sources of shame right away, which you can see on our satisfaction survey peer education isn't merely valuable it's absolutely necessary in people quitting.

From the outset we knew that CHOICES would succeed if we provided intensive training to consumers, it's a 30-hour curriculum about the facts about tobacco trying to dispel many of the myths that Chad talked about. We actually teach them how to work with smokers, the contemplation, pre-contemplation, meeting people where they're at is, is going to be a skill that the CTAs will need.

We also do some training and advocacy because as I said we were trying to create a demand for services so CHOICES was literally creating those consumers who would testify and at hearings who would work on committees and who would speak up for those people who weren't already aware that they could actually quit.

We were also submitting, we were using the CHOICES program as a way to collect surveys so that we had, we had a very quantitative description of the fact that consumers want this kind of service.

So we basically structured two types of contacts that the CTAs make in a meeting. They either provide group sessions, which could be fairs, health fairs or they would go to provider agencies, community health centers, they've done a lot of workshops and the part of the session that has to do with the group is general information, letting people know about choices as a support and a lot of personal stories so that they can hear the consumer voice not just the voice of people who want them to be well but the people who have actually succeeded.

After a group session we invite consumers who are ready to learn more about themselves to an individual conversation. It's a very brief conversation but everything that we talk about is unique to them so they can tell us anything that they haven't already heard and we can validate that their situation is, you know, we can still do something with treatment.

So from the group context when we're talking to, you know, groups of people, groups of providers we hear that there are some pretty consistent reasons for wanting to quit, their health, the cost, the smell, a lot of people don't like the smell or the taste.

A lot of people feel as though they're worried about their children, they're hearing about you know, second hand smoke and third hand smoke and they're also aware that their dependence on tobacco is somehow related to dependence on other struggles that they may be having with substances that they smoke, when they drink they drink when they smoke or relationships like that.

And the barriers that they talk about, again Chad spoke about some of them, worried about how will you cope if you think that cigarettes are helping you cope. What are you going to do if you gain weight, one of the strongest messages we hear is what else would I do, what else is there to do related to isolation and boredom frankly at some of the programs in the community.

What if everyone around me smokes, what kinds of self-advocacy would a person need to suggest to people they live with that they stop smoking or smoke somewhere else.

What if I don't have the willpower? A very strong sense that if I tried and failed I haven't really tried and that I failed, and again consumers don't need any more messages of failure. And of course where is free treatment once we can help people understand that NRT or prescription therapy is something that will greatly enhance their chances?

So the personalized feedback, which we've invited people to be part of, so they're choosing to be part of that, they own all the information from these sessions. We do a carbon monoxide score and we give them the feedback, usually this is, this has a big impact on people and they can see the short term benefits to quitting that they could simply, you know, get that number a little lower.

We talk about the cost of cigarettes for the year and what people would do with that kind of money. A lot of times it's the one time when people can talk to us about their medical histories and predispositions and the relationship to smoking. And of course we can give them resources, educational resources and referrals to treatment.

Usually there, you know in a lot of the education and the personalized feedback we can show people the whole cost issue. A lot of consumers obviously react to that. The tools that we'll be able to work with them on are, you know, let's see what else you could, if you weren't spending this kind of money. So we would be able to calculate that and it would be a unique number for them.

And then when we show people this type of hard data about how much money they are spending and that it's not just them, that there's a whole group of people well described by Chad earlier in the Webinar, that they can see that this is, this is a big problem and that some of the talking that we need to do about it is they have to help us with that talk and create the demand, we can't ignore it anymore.

So some of the accomplishments of the CHOICES program that we're extremely proud of, we've become a best practice resource in a few packages. We've completed 380 site visits in New Jersey. We've interacted with 12,340 consumers in the state and presented at 31 conferences and 37 non-consumer events. We did win the Mental Health America Innovative Programming Award in 2007 and recent won the American Psychiatric Association Award in 2009.

Just a month ago our evaluation of CHOICES as a program was published in Community Mental Health Journal online.

We've created a Web site, www.njchoices.org that includes stories from consumers some in New Jersey and some nationally, about their success. Consumers can read and hear about lots of people have done this and so can you.

We also publish a newsletter and we've had thousands of hits, continual requests for the newsletter, continual requests for visits from CHOICES and actually very hard to keep up with the demand at this point.

I want to talk a little bit about how we pulled this off in New Jersey. When back in 2001 the Robert Wood Johnson Foundation wanted to get together with the Substance Abuse and Mental Health Services Administration because it was becoming very clear the data was being collected that this population was actually a big public health issue.

So what resulted from those kinds of conversation was that we had data to get some money from the American Legacy Foundation, the Foundation that was started with the tobacco settlement money. We were also able to get other moneys from traditional public health organizations such as the American Cancer Society and the Cancer Institute of New Jersey.

We had so much success and we had it so fast that we were able to get matching dollars from the New Jersey Department of Human Services within a year and when we lost some of the other dollars our Division of Mental Health Services took over the funding for the entire project and they have managed to sustain that for us even in very difficult budget climates like this year New Jersey is having a very difficult budget.

So for that we're very grateful for the support from our Special Assistant for Consumer Affairs, Margaret Molnar. I'm going to turn it back over to Leslie and maybe we can get into some questions.

Leslie Brenowitz: Thank you so much Marie and all of our presenters.

Just to let you know what else is available in this slide deck before we move on to the Q&A just quickly a slide of some resources including access to the CHOICES Web site where there are lots of materials as well as access to some of the toolkits and resources our other speakers mentioned, the biographies of our speakers and contact information for our speakers if you have interest in following up with them after the fact.

We'll now take questions from callers. To ask a question, please dial star 1 on your telephone keypad to be placed in the queue and give the operator your name. The operator will announce the name that she is given, so if you do not wish your full name to be announced then please only state your first name when talking with the operator.

Upon hearing the operator announce your name please ask your question and I will ask all participants to try to keep questions brief because I know we've got a lot of folks that want to know more, and after your question your line will be muted and the presenters will respond.

You can also enter questions through the Q&A feature on the live meeting software. I will add those questions in and I'll just say if we don't get to your question whether it be written or by phone we will make every attempt to get to you after, and I'll come back and talk about that.

So operator if we could please have the first question?

Coordinator: We do have a few questions. One moment. Our first question comes from (Elana Fines). Your line is open.

(Elana Fines): Hi. (Elana Fines) from St. Vincent's Hospital. We went through an experience where clients were joining our smoking cessation program very participatory and then there was a change in the (OASIS) regulation, that's the substance abuse regulations in New York State and our environment needed to become substance abuse free.

And we found that in that environment since then clients have been less interested and willing to participate in smoking cessation groups trying different kinds of nicotine replacement therapies and I'm wondering if anybody has any thoughts about how we can kind of re-invigorate and help our clients. Our assessments is that the demand not to smoke in the environment kind of backed people up against the wall.

Marlene Reil: Well I think I can, this is Marlene and I can start to address that being in New York City and knowing about the (OASIS) regs. I know that you had to put in place these environmental policies and may not have gotten the feedback of your consumers in that policy and you might want to try to go back and see what you can do to encourage their inclusion in creating a policy that works for everybody that's still in line with the (OASIS) regs.

Because I think it's really important for them to know that this is our program and this is something that we choose to do together and while we have to, follow state regulations there's a certain aspect of this that's in our control and how we want to be responsible for our behaviors and actions.

So that would be my suggestion to you because it does feel that it's not in their control and some way to make that be more controllable for them would be helpful.

Marie Verna: This is Marie Verna. In New Jersey we also changed the environment. We actually had a law passed our senate president, or the chair of our health committee is very, very active in mental health and we did manage to pass a law that all, even community mental health centers had to you know, had to have non-smoking policies and we had been very active in changing the situation in all of our state hospitals.

And I would agree that once it became a discussion of lack of control, the response was different, it stopped being a conversation about do I want to quit versus is somebody telling me to quit and then there would be, you know, a lot of conversations about well the rest of the population smokes or I'll quit when, you know, my provider quits or when my case manager quits.

But what we did in New Jersey was we actually formed committees of consumers and providers, bring all the stakeholders together in each hospital there was a committee, a wellness committee and in that kind of environment there was, at least the consumers had a voice.

And they were able to talk to other stakeholders, you know the administrators of the hospital, the management of the hospital, the providers themselves and it, I think when you give the consumer the voice and you honestly listen to them it changes the dynamic and you have to create those forums for that, you can't just you know, they're not, those forums don't just create themselves. That's all.

Leslie Brenowitz: I'll also just add, this is Leslie, and I know this came up on our previous training teleconference that the NASMHPD, National Association of State Mental Health Program Directors, did a study that you can get on their Web site about smoking policies in mental health facilities, that might be of interest.

I want to share now a question we received online from (Anne). This question is particularly directed to Chad. There have been many warnings about the possible neuropsychiatric effects of Varenicline.

Chad Morris: Varenicline.

Woman: Varenicline.

Leslie Brenowitz: Thank you. On the general population. Is there increased risk of the drug causing or worsening psychiatric symptoms in mental health patients?

Chad Morris: Those clinical trials are ongoing right now so the post FDA approval Pfizer was required to look at specific mental health diagnoses, so those are currently underway. But what I can tell you is that in the initial studies leading up to FDA approval that those, that that was not seen but they didn't specifically, what happened with the original FDA approval studies is they excluded folks that had current mental health diagnoses.

So the best I can say right now is those studies are ongoing.

Leslie Brenowitz: Thank you. Operator can we take another telephone question?

Coordinator: Our next question comes from (Susan Isles). Your line is open.

(Susan Isles): Hello. When I moved into Senior Housing I was not a senior and there was social pressure against smokers, not today but then. Also I relied heavily on my medication, which has a tranquilizing effect. I had no nicotine patch or other anti-smoking medication just anti-psychotic.

And also I had spiritual support of the stigma associated with smoking around church. So I quit in 1994, I just wondered if any of those elements were considered, especially the reliance on medication that you're already taking and whether it has an impact on smoking cessation efforts?

Leslie Brenowitz: Any of our speakers have...?

Marie Verna: This is Marie. I just want to clarify the, first of all congratulations on being smoke free since '94. Is your question whether or not the meds you were taking for your mental illness affected your ability to quit?

(Susan Isles): I felt I could rely on them because they were tranquilizing and I also just recently quit drinking diet coke, so I know that my medications helped me in cessation efforts.

Marie Verna: Okay your mental health drugs?

(Susan Isles): Yes.

Marie Verna: Okay. That's great because you were able to deal with the stress.

(Susan Isles): Oh yes, I had social pressure, I had influence, concurrent influences that came together which would be a useful direction to take in peer counseling.

Marie Verna: Yes. Definitely. Yeah. And I think the other item you mentioned the spiritual.

(Susan Isles): Yeah. I go to (Newman) Hall Holy Spirits Catholic Church in Berkeley.

Maria Verna: Okay, okay great. These are the kinds of things that we can do in all kinds of peer counseling that people can talk about you know, not just the meds and not just the treatment but all the things that support them in their smoking and it's a unique thing, it's a unique road.

(Susan Isles): Do anti-psychotic medications which are tranquilizing have the potential to help smoking cessation efforts?

Maria Verna: I believe Chad mentioned that there, some of the anti-depressants...

Chad Morris: Yeah I can...

Woman: Yeah Wellbutrin is one medication that's an anti-depressant, Buproprion...

Maria Verna: Yeah.

Woman: ...also helps.

Chad Morris: I can speak to that a little bit too. One medication that's not used as commonly anymore that does really encourage smoking cessation is Clozapine, but there are some side effects along with that, but that's one that's very well established in the literature that shows that it does help with smoking cessation.

(Susan Isles): Okay. Thank you all.

Leslie Brenowitz: Thank you. Here's another question that has come in online from Joyce and that is has anyone utilized a quit line as a follow-up in a treatment plan after consumers leave in-patient centers and if so has it been successful?

And Chad I know you mentioned quit lines in your presentation, does anyone know of studies that have sort of followed patients in the transitioning from in-patient to out-patient and maintaining their non-smoking status?

Chad Morris: Well, you know this is very timely in that there's a paper coming out that you know, I had helped with the National Group of Quit Line Providers and so this is basically I think asking in the continuity of the care moving from an institutional setting to the community did quit lines help.

We don't know the answer to that. There's no studies that have specifically been done on that but we do know that lots of folks with mental health disorders are calling the quit lines and we're currently looking at building systems of looking at outcomes for those populations.

Leslie Brenowitz: Thank you. Another online question and this is directed specifically to Marie, though I might invite all the speakers to contribute if they have other ideas. The question is please discuss the counseling provided that helps consumers replace smoking with other activities.

Marie Verna: I think we try to look at what are your life goals, what was recovery for you and that changes from one person to another so that we can then go into some more discussion about well what kinds of things would you be doing to move towards that.

And if smoking because you're bored isn't leading you towards your overall goal, then it's a, it's a perfect way for us to sort of make that connection between mental health recovery and wellness and the fact that the isolation and the boredom are things that in any way that, your road is going to go you're going to have to find things that lead you there.

And so you know, we do, we definitely try to replace some, at least in the Community Mental Health Center that I'm working in now, you know, I will deliberately ask people, you know would you like to form a walking group that would walk during the breaks or walk at lunch instead of going to the smoking section, you know, outside.

We ask people to really think about it more in terms of really what they want in life and how does this affect it. A woman who was trying to heal relationships with her family, many, many painful things have happened with her family of origin and with her children.

We were able to link her smoking to efforts to heal her family, which she had been working on with her therapist and her doctor, to the fact that her children didn't like to come over because the way her house smelled. So her prime motivation is to quit smoking for that reason and all of the things that she could do to replace that behavior had to do with getting to that goal, it's her primary dream.

Leslie Brenowitz: Thank you. Operator let's take another call.

Coordinator: Our next question comes from (Medica) Health Plan. Your line is open.

Man: I'm curious on clarity on exactly who are the peer educators that were in those programs within New York and New Jersey? Do you mean other individuals with mental illness who have had success with tobacco cessation or what is the peer helper?

Marie Verna: Yeah. This is Marie in New Jersey. We actually, the job description required that you were a person who had received services that you were comfortable with calling yourself a peer specialist which involved disclosing that you have a mental illness.

In our case we needed people to have transportation, they had to have cars and drivers licenses and they also had to be comfortable with driving long distances because that was, you know that was part of the job.

As far as their smoking, yeah they had to be people who had had success, were comfortable talking about it and motivating others but not in any kind of judgmental way. You know sometimes when some of us beat a negative habit we become, you know we all the sudden want a lot of other people to do that too.

But you know we trained, we trained them on techniques for working with people who aren't for, you know aren't as active as they perhaps were. But they were all requirements of the job.

Marlene Reil: So for us in New York City the eligibility requirements to be a part of our six month training program is that they were already, they were peer specialists who were currently working in a mental health service setting for a minimum of six months, we required that so that they could complete some of the tasks that the project required, which one of which was to create that project plan with their supervisor and their agency that they could implement after the workshops occurred.

There wasn't a requirement of any particular success in health goals that they met, but it certainly was something that added to their eligibility if they put it on their application, we really liked hearing about their personal statements and their personal victories and their journey. So that definitely led to some of the choices that we made, because we did have a large applicant pool.

Man: Thank you.

Leslie Brenowitz: An online question and I'm not sure if this might have been answered by the slide Chad where you talked about drug interactions. But the participant is asking about I would like to know more details of the lesser known drug interaction, Zyprexa and Clozapine are well known.

Chad Morris: Right. Well by drug interactions you know, you're either talking about the interaction between tobacco use and medications or you're talking about the use of nicotine replacement therapies and other medications.

Leslie Brenowitz: Right.

Chad Morris: So to speak briefly to both of those, again we know that your plasma levels with a lot of psychotropic medications once you quit can as much as double. So again, just making the point you need to work with your provider to make sure you're not experiencing any increased side effects of those medications and to make sure the levels are correct.

As far as the interactions between something like nicotine replacement therapy and psychotropic medications there's really none that we know of. So nicotine replacement therapy is extremely safe.

Leslie Brenowitz: Thank you. And there is also a question about symptoms and side effects that you may have seen with smoking cessation medications and depression with adolescents?

Chad Morris: Smoking, so if they're using smoking cessation medications, if that's increasing depression, is that the question?

Leslie Brenowitz: Or you know yeah, and if there are any side effects from those smoking cessation medications that might affect someone's work with adolescents.

Chad Morris: Well you know we don't know a lot about youth and for all these things you know, the medications are not FDA approved for youth. That doesn't mean they're not being used.

Leslie Brenowitz: Right.

Chad Morris: But at the same time for instance with, we mentioned Buproprion, actually if you're using Buproprion for depression and smoking you would expect depression to decrease as folks smoke potentially.

We're not seeing that, you know the thing is that when people quit smoking a withdrawal symptom is, it looks like depression so it's very hard to kind of untie what's really just smoking withdrawal and what is really depression, and so that's really where you got to get into the history, the clinical history of each individual.

Leslie Brenowitz: Thank you. Let's take another call in question.

Coordinator: Our next question comes from (Pete Fragert). Your line is open.

(Pete Fragert): Hello how are you today? I'm wondering since the tobacco market's 40 percent towards people with mental health problems why we're not getting 40 percent of the settlement money.

Chad Morris: That's an excellent question.

Woman: We wish we could answer it.

(Pete Fragert): Well thanks for considering it but it's not a joke.

Chad Morris: I know.

Marlene Reil: Well we under, I mean in the public health you know we do also see that population of the general population is getting smaller and so we are really starting to drill into this "special populations" who are the most at risk and who smoke the most. So I think that you're very right and needing to always reinforce to those funders at city and state levels that it's really important that some of the money, more of the money trickle down into mental health and substance (unintelligible).

(Pete Fragert): We could use the money to send people with mental illness that had their college educations truncated back to school.

Marie Verna: Right. And I think, this is Marie in New Jersey. That was part of why we trained the tobacco cessation advocates in advocacy because we were, while we were getting people interested in trying to quit we were also creating a network of consumers who would speak out, and in New Jersey not just consumers, we have a very strong tobacco advocacy community.

And we have published you know, policy statements on you know, directed at the tobacco industry. In some states it's more difficult than others. I'm aware that in Virginia the Attorney General actually got involved because it's a cash crop for that state. But that is the, that is the reason that we not only need to get consumers interested in quitting and helping them quit but we need the advocacy to come right from consumers.

Leslie Brenowitz: Thank you.

(Pete Fragert): Thank you.

Leslie Brenowitz: Here's an interesting question that came in online, would you advocate adding nicotine testing to our panel of substance use tests or should we take a "softer" approach?

Chad Morris: Well I would, you know this is Chad, you know there's been a national movement to right now make that happen and I would advocate strongly for that.

You know we used to talk about alcohol, tobacco and other drugs and somehow along the way we lost tobacco. So the T in the equation became silent and that's in part why folks, you know see tobacco use as not a drug they see it as different. So I really believe strongly that it does need to be integrated into those systems.

Marie Verna: This is Marie. Again I would also agree with Chad strongly. We've tried very hard to make sure that everybody's still remembering tobacco as a dependent or addictive substance and in fact a lot of the success that people have, I don't know if anyone's mentioned that a lot of consumers say that quitting smoking is harder than quitting any other substance they ever used, including heroine, crack cocaine, very, very strong substances.

But if you will talk about it as something that needs to be assessed at the very beginning, definitely needs to be part of a medical assessment you can leverage the fact that somebody's already beat one addiction and that some of the same behavioral changes that they brought about for themselves with regard to stronger and different substances are going to play out here.

You know if you get treatment, if you get support. If you have a plan that's reasonable and workable and realistic, all of those same strategies are realistic and there's a high chance you're going to quit.

Marlene Reil: Well I have to say that I think that in order for any kind of program to mandate that kind of testing they would have to have commensurate staff training and an ability to treat lack of cessation, and even at that point I'm not sure if you know if it's something that wouldn't be required for some other (unintelligible) reason.

So I think it's really important that the competence be at this basic standard before any of that kind of mandatory testing goes on.

Leslie Brenowitz: Related to substance use there's a number of questions that are coming in online. They're related having to do with, on the one hand how do you address this issue when you're working with someone who has multiple addiction and then somewhat related someone's experience showing that client's trying to quit substance abuse smoke more.

And you know, so those things being related how do we deal with multiple addictions and I guess sometimes the transfer of addiction from one kind of drug to another, in this case being tobacco, nicotine rather.

Chad Morris: But you know, I can start on this, and again I think philosophically this is an incredibly important question because if tobacco isn't factored into the equation in substance abuse treatment to the same extent as other drugs, basically what you're doing is you're allowing someone to continue an addictive process and to cope through an addictive process.

So they can go through their alcohol abuse, their cocaine abuse treatment but if they're still coping through an addiction process they're just reinforcing those other addictions.

And so that's why we see in the slide that I mentioned that you actually see an improvement if you're doing both of these concurrently, tobacco and the other drug. So I would start with that but what do the other presenters have to say?

Marlene Reil: No I totally agree Chad that, this is Marlene, that to address all addictions at once, you know we normally don't say well, you know, we're going to deal with your heroin addiction today but we'll leave the cocaine addiction for another day.

We usually encourage all of these addictions, that we encourage abstinence or harm reduction of all substances, and smoking is among the most dangerous of the substances even though it's legal.

So I think it's important to at least as baseline have smoking be in the conversation but, and be a part of all addiction treatment.

What is lagging behind as I said before is that competence that all addiction specialists are trained in smoking cessation as a part of their curriculum when they're in school and when they come out that they can demonstrate some competence in that area.

Marie Verna: I agree with Chad and Marlene here in Jersey, Dr. Williams is, you know, Assistant Director of our Department of Addiction Psychiatry and it, there's no question about it that if it's addictive behavior, if it's addictive, if it's dependence it is all the same thing. I think that what I was saying is that you can help somebody see their success in one area and how it relates to the strength and the stamina that they'll need for another area

And I agree that it all has to be integrated all at the same time, you know partly because some of it is self-medicating because of the pain of mental illness. And I agree with Marlene we're doing a lot of training here in the state, we're doing a lot of training nationwide because that's no longer good enough to say you know for providers to say well I don't know that field so I don't feel comfortable prescribing, I don't feel comfortable.

We have, we're building an assessment tool here in Jersey that you know, it's got to be part when you bring somebody, you know when you're doing an intake it has to be part of what you're looking for and it's got to be something that you're paying attention to.

My observation is that it actually is something that's quite important to consumers that they really want to take care of and it's, I really think, that the lack of conversation about it in, you know that conversation has started in the last four years, five years.

And that was really necessary just to hear consumers talk about how this is you know, I don't, my goal is not necessarily to go to group my goal is to stop smoking.

Leslie Brenowitz: Thank you. Let's take another call.

Coordinator: The next question comes from (Craig Hunzel). Your line is open.

(Craig Hunzel): Hello. It appears that most people advocate not just the nicotine replacement therapies but also counseling to go along with the treatment. I'm the Medical Director of a mental health authority and I've had a real hard time getting the counseling and trying to get someone to do that and a lot of our patients are unfounded.

So I guess the question, I have a couple of questions. Number one are there other, are there good resources for counseling and number two it sounds as if the peer support program is actually providing the counseling.

Chad Morris: So one of your prime references or resources is your Quit Line because even if, most every Quit Line some might not have the NRT offered but all of them have the telephonic counseling, so I would encourage you right off the bat to start using that.

Marie Verna: Yeah. We also here in New Jersey we developed a toolkit learning about healthy living which is part of the (NASBIT) toolkit on wellness and recovery. I'm not sure if it was listed as one of the references but I can certainly get that information to you.

Marlene Reil: And also in addition, I mean in New York City as well is encouraging mental health and substance use providers too provide smoking cessation treatment. We also have dedicated smoking cessation programs of varying, some are you know, pay out of pocket, some are free, some take Medicaid that are available for folks who want to increase their support in addition to medication.

Chad Morris: You know and one additional point is what we've been doing in training with various states is you know, up through mental health and substance abuse authorities are saying this doesn't need to be a stand-alone program, really you can integrate this in the wellness programming and the overlap is great. And so if you look at your community providers and look at who's doing wellness and add this on that the add-on is you know, not much. So that's kind of how we create the buy in the states we work with.

Marlene Reil: And in some states that wellness is reimbursed under certain insurance plans so that's, it's excellent.

Leslie Brenowitz: Thank you. I know we have some more questions that came in online and I would imagine we have more people holding. Unfortunately our time has run out; however, we do want to respond to your question. If your question came in online we will download those after the call and consult with the speakers to respond back to you.

If you are holding on the phone and we were unfortunately not able to get to your call, I do encourage you to send your question to 10x10, that's 10x10@samhsa.hss.gov and again when we receive your questions that way we will consult with the speakers and send you back a response.

I want to thank our speakers, Chad, Marlene, and Marie so much for your work on this issue and for sharing your insights today and also to all of you who came online and called in for caring about the topic and for taking time out of your afternoon to learn more.

The PowerPoint presentation, a PDF version, an audio recording, and a written transcript of this call will be available within a couple of weeks on the 10x10 Wellness Campaign Web site, the address is here on the slide.

And I also wanted to let you know that you will be receiving from us tomorrow if you were part of the online version, an e-mail with a request to participate in a short, anonymous online survey about today's training.

It would only take you about five minutes to complete the survey and I really encourage you to take the survey, share your feedback with us, share your ideas for future topics that we could cover in these types of events and again I want to thank our speakers and thank all of you for listening and for your participation today.

Chad Morris: Thank you.

Woman: Thank you.

Leslie Brenowitz: I'll ask my speakers to just stay on the line for a moment.

Coordinator: Thank you. That does conclude today's conference call. All participants may disconnect at this time and thank you for joining.