1. We Still Haven’t Come a Long Way, Baby! Smoking Cessation Efforts in an Oregon CTP Lucy Zammarelli – Willamette Family, Inc. Barbara Tajima, University of California San Francisco CTN Steering Committee Presentation Bethesda, Maryland September 21, 2010 This work was supported by the National Institute on Drug Abuse (R01 DA020705), by the California-Arizona research node of the NIDA Clinical Trials Network (U10 DA015815), and by the NIDA San Francisco Treatment Research Center (P50 DA009253).

2. Willamette Family in Eugene, OR  Residential facilities for men; women and families  Women’s facility houses a Child Development Center on-site for women with young children, and pregnancy services including pre- and post-natal care; men’s facility focuses on criminal behaviors and behavioral interventions.  Designated smoking areas for clients at both facilities  Substance abuse treatment for men and women  Gender responsive treatment models with strong 12-Step influence, CBT, Relational Theory, MI, Peer services  Mental Health Services added to programming part-way through the study  Trauma treatment, depression, anxiety, infant attachment issues

3. “Addressing Tobacco Through Organizational Change” (ATTOC) EBT  Developed by Hoffman and Slade (1993) to address tobacco use in tx programs in New Jersey  Adapted by Doug Zedonis at UMDNJ  12-step approach to implementation  6-month manualized intervention  Core strategies  On-site consultation and training  Formation of tobacco leadership group  Policy development and model interventions focused on a “Quit Center” approach and included NRT, NicA, tobacco use assessment and treatment planning for abstinence from use

4. Staff Training and Supervision  National training experts—on-site training and monthly conference calls  12-step model for organizational change  Establishment of the TLC (Tobacco Leadership Committee) and new agency Tobacco Policy  Use of CO monitors and NRT  Establishment of on-site NicA meetings  Support and goal reinforcement, put the T in ATOD!  Monitoring and data collection by research staff

5. Implementation Barriers  Addictive nature of tobacco  It’s a brain thing…  Staff resistance  Free choice, believed agency could not dictate personal habits  Client resistance  Social aspect of smoking for decompression, stress reduction  Provided a break from children  Limited economic barriers  Cost of NRT, medications  Additional burden of treatment

6. Outcomes

7. Aims  Change organizational practices related to smoking using the ATTOC intervention:  Changes in staff knowledge, attitudes and practices (KAP)  Changes in client knowledge, attitudes and services (KAS)

8. KAP sample scale items (Staff)  Knowledge:  Hazards of smoking have been clearly demonstrated  Smoking increases risk of heart attack  Barriers:  Lack of reimbursement  Lack of impact on patients  Self-efficacy:  My patients follow my advice about behavior change  If counseled patients who smoke what percentage would you think would quit smoking?  Beliefs  Smoking personal decision which does not concern counselor  If in recovery less than 6 months quitting smoking would threaten sobriety  Practices  How often advise patients who smoke to quit  Encourage patients to use NRT Source: Delucchi, Kevin, Tajima, Barbara & Guydish, Joseph (2009). Development of the smoking knowledge, attitudes and practices (S-KAP) instrument. Journal of Drug Issues, 39, 347-364.

9. KAS sample scale items (Client)  Knowledge:  Hazards of smoking have been clearly demonstrated  Smoking increases risk of heart attack  Attitudes  I am concerned about smoking  Clients who smoke want to quit  Program Services  Counseling for quitting smoking is important part of program’s mission  Provided with educational material about quitting smoking  Clinician Services  Clinician encouraged you to quit smoking completely/encouraged NRT use  Clinician has skills to help me quit smoking

10. Methods  Data Collection (pre, post, follow-up)  Staff surveyed (knowledge, attitudes, practices)  Administrative and clinical staff  Clients interviewed (pre, post, follow-up)  Convenience sample of N=50 at each time point  Minimum 10 days in treatment  Nicotine Replacement Therapy  Offered to staff and clients  Nicotine patch and gum

11. *Significant pre to post p<.05 **Significant pre to fu p<.05 Changes in Staff Knowledge, Attitudes, Practices

12. * Pre to Post and Pre to FU Significant p<.05 Client Knowledge, Attitudes, Services over time (cross-section)

13. Staff/Client NRT use over 10 month period

14. Staff Smoking Prevalence

15. Client smoking prevalence at Pre, Post and Follow-up

16. Sustaining the Model  Challenge of addressing tobacco treatment  Model continues but practices have degraded  Without vigilance and administrative reinforcement  Tobacco addiction, like other addictions, is cyclical in nature  Lack of resources for NRT/medications  12-Step myths just won’t let go…  Move toward co-occurring treatment models  Training mental health staff  Client rights and the right to smoke  Smoking during pregnancy continues to be a big issue

17. What have we learned?  Commitment and flexibility  Use of the wellness model most successful  Integrated into clinical supervision  Use of NRT/medications most helpful  External pressures  Health care reform encourages a more medical model  State Administrative Rules  Health care issues among staff are the greatest predictors of continued cessation  Economic resources  Need for NRT  Support for Tobacco Cessation classes, groups

18. Nic-A Serenity Prayer  God grant me the Serenity to accept the things I cannot change... Courage to change the things I can and Wisdom to know the difference...  Grant me patience with the changes that take time, an appreciation of all that I have, tolerance of those with different struggles, and the strength to get up and try again...  One day at a time.