1. Incorporating Tobacco Cessation Activities in a Psychosocial Rehabilitation Clubhouse Colleen McKay, M.A., C.A.G.S. The Program for Clubhouse Research Center for Mental Health Services Research Department of Psychiatry University of Massachusetts Medical School

2. Extent of the Problem Many people with Severe Mental Illness (SMI) use smoking to manage symptoms, stress, or increase social contact and consume nearly half of all tobacco sold in the United States. Compared with the general population, individuals with SMI are at greater risk of co-morbid health problems and premature death. Often individuals with SMI are unaware that services like Quitlines, Nicotine Anonymous (NIC-A) meetings, and/or NRT exist.

3. Health Promotion Activities Currently Provided by Clubhouses 1 Percent 1. McKay, C.E. & Pelletier, J.R. (2007). Health Promotion in Clubhouse Programs: Needs, Barriers, and Current and Planned Activities. Psychiatric Rehabilitation Journal, 31, 155-159.

4. Our Project Academic community partnership that joins experts in tobacco dependence treatment for adults with SMI from UMass with leaders in the Clubhouse Model from Genesis Club in Worcester, MA. Expand member involvement & develop peer tobacco leaders Adapt & integrate tobacco interventions for clubhouse settings: Learning About Healthy Living (LAHL) Addressing Tobacco Through Organizational Change (ATTOC) Consumers Helping Others Improve Their Condition by Ending Smoking (CHOICES) Create new materials based on these interventions, and Disseminate findings

5. Our Team Colleen E. McKay, MA, CAGS, UMass Douglas Ziedonis, MD, MPH, UMass Gregory Seward, MSHCA, UMass Valerie Williams, MA, MS, CMHSR; UMass Robert Orwin, Ph.D., Westat Kevin Bradley, MED, Genesis Club, Inc. Jennifer Colburn, AA, Genesis Club, Inc. David Rocheleau, BA, Genesis Club, Inc. Emily Sawyer, BA, Genesis Club, Inc. Jim Damiano, BA, Genesis Club, Inc. Genesis Members – Laura, Jane, Paul, April

6. The Clubhouse Model Originated at Fountain House in 1948. Worldwide network of clubhouses affiliated with the International Center for Clubhouse Development (ICCD) 328 clubhouses - 27 countries & 32 states. Clubhouses - therapeutic communities composed of people diagnosed with Severe Mental Illness (SMI) and paid staff Participants are referred to as members Clubhouse staff and members work side-by-side as peers in a rehabilitative environment Members are encouraged to participate in all aspects of clubhouse operations Clubhouses are typically open 365 days a year.

7. Basic Clubhouse Components Membership Choice Work-Ordered Day Community Supports Employment Supported Education Housing Outreach Wellness or Health Promotion Activities Evening, Weekend & Holiday Programs

8. Genesis Club Free standing clubhouse established in 1988 ICCD training center 120 members per day Active monthly membership of 300 Membership: 47% male, 25% non-Caucasian, and average age 43 years. Approximately half the clubhouse members have a diagnosis of schizophrenia, and 1/3 have major depression or bipolar disorder. Many clubhouse members struggle with substance misuse: 17% have severe to moderate substance abuse, 10% have mild substance abuse, and 24% are currently abstinent.

9. Genesis Club: Existing Health Promotion Activities Structured Exercise Program 2 Gym Memberships at a Local College Walking Group Running Group – Falmouth Road Race, Worcester Fireman’s Run Nutritional Meals/Healthy Food Choices (e.g. Salads at Lunch/Dinner) 2. Pelletier, J., Ngyuen, M., Johnsen, M., McKay, C., & Bradley, K. (2005). Integrating Structured Physical Exercise into an ICCD Certified Clubhouse Program: Results of a Pilot Study. Psychiatric Rehabilitation Journal, 29(2), 89-96.

10. Genesis Club: Extent of Tobacco Use Among Members 82% of members (N=114) said they endorse smoking related behaviors Many members (49%) want support with reducing tobacco use 38% want to quit using tobacco Other members want support with relapse prevention

11. Addressing Tobacco Through Organizational Change (ATTOC) Guides a technical assistance process utilizing specific steps and organizational change processes: selecting leaders, leadership team, and workgroups; determining goals; assessing agency readiness for change; creating a change plan; developing implementation teams to address the specific client/patient, staff, and organizational goals; develop communication plans, and provide ongoing supervision for the integration of evidence based practices, educational curriculums, and agency policies to address tobacco.

12. ATTOC in the Clubhouse Develop an organizational change plan with regard to tobacco use For clubhouses, goal areas focused on: 1)Organization-Clubhouse, 2)Service Providers-staff, and 3)Service Recipients-members

13. ATTOC Goals and Activities Program level: Short-term goals: ongoing education about the effects of smoking and tobacco use, Pilot and modify tobacco cessation interventions for the clubhouse Long-term goal: tobacco cessation becomes part of the health promotion activities at Genesis. ATTOC staff / member goals: participation in tobacco cessation training, intervention development, developing education and recovery resources, and a reduction in tobacco use.

14. Developed to help smokers at any motivational level to quit Training Manual - 8 Sections Introduction to Learning About Healthy Living General Structure of a Treatment Group Tobacco Dependence Treatment Medications Group I (Motivational Group for lower motivated) Facilitator’s Guide Consumer’s Handouts Group II (Quit Group for higher motivated) Facilitator’s Guide Consumer’s Handouts Appendix/Forms, Resources, and References Learning About Healthy Living (LAHL) 3 3. Williams, J.M., Ziedonis, D.M., Speelman, N., Vreeland, B., Zechner, M., Rahim, R., & O’Hea, E. Learning about Healthy Living: Tobacco and You Manual. Revised June 2005.

15. Learning About Healthy Living Group I Introduction to Healthy Living Educational and Motivational Accepts all smokers with SMI – Clubhouse members, participants in Day Program or other services Tobacco and smoking education within context of Healthy Living: Exercise, Stress, & Diet, Health Risks, Chemicals in Cigarettes/Smoke/Second Hand Smoke, Tobacco Addiction, Mental Illness & Medication Effects, What Are My Smoking Patterns?, What is Carbon Monoxide? Treatment Options Making a Decision to Quit, Cold Turkey, Nicotine Replacement Therapy (NRT) & Other FDA Approved Medications 20 Weeks - Could change the order of the sessions and some may take longer than 1 session

16. Learning About Healthy Living GROUP I: Session Outline 1.Starting on the Road to Healthy Living 2.Why is Smoking Dangerous? 3.What’s in Cigarette Smoke? 4.Why Do So Many Consumers with Mental Illness Smoke? 5.What is Carbon Monoxide? 6.How Much Does Smoking Cost? 7.How Does Tobacco Advertising Affect Me? 8.What is Second Hand Smoke? 9.How Are My Medications Affected by Smoking? 10.Why are Cigarettes Addictive? 11.What Are My Smoking Patterns? 12.How Can I Better Manage Stress? 13.How Much Physical Activity Do I Need? 14.How Can I Make Healthier Food Choices? 15.Why Should I Quit Smoking? 16.What if I’m Not Ready to Quit? 17.Is it Really Possible For Me to Quit Smoking? 18.What Happens when I Quit Smoking Without Help? “cold turkey” 19.How Do Medications Help me to Quit Smoking? 20.Which Medications Should I Use?

17. Monthly Budget as a Percentage of Median Public Assistance Received* Food Shelter Misc. Living Expenses Cigarettes *Source: Steinberg ML, Williams JM, Ziedonis DM. (2004). Financial Implications of Cigarette Use in Smokers with Schizophrenia. Tobacco Control, 13, 206.

18. Session 6: How Much Does Smoking Cost? Tobacco companies only spend 6 cents to make a pack of cigarettes Review how smoking is expensive Average daily, weekly, monthly and annual amount spent on cigarettes A pack a day smoker can spend $3000 per year Can be about 25% of a consumer’s income Learn how much one will save if he/she quits smoking Identify other things that could do with the money saved

19. How Much Does Smoking Cost You? For 1 Pack Per Day: “In 10 years you will spend at least $32,760 …what else could you have bought with that money?” If YOU Quit Smoking… YOU WILL SAVE A LOT OF MONEY! Approximate Number of Cigarettes Smoked Average Cost Per Day Average Cost Per Week Average Cost Per Month Average Cost Per Year Average Cost in Ten Years ½ pack (10 cigs)$4.50$31.50$133.88$1,638.00$16,380.00 1 pack (20 cigs)$9.00$63.00$267.75$3,276.00$32,760.00 1 ½ packs (30 cigs)$13.50$94.50$401.63$4,914.00$49,140.00 2 packs$18.00$126.00$535.50$6,552.00$65,520.00 2 ½ packs (50 cigs)$22.50$157.50$669.38$8,190.00$81,900.00 3 packs (60 cigs)$27.00$189.00$803.25$9,828.00$98,280.00

20. Carbon Monoxide (CO) Meter CO Monitors yield accurate, non-invasive readings of carbon monoxide levels which quickly and reliably tracks tobacco use; tobacco use reductions, and self-reported smoking status.

21. Group II: Quit Smoking Group Designed for the motivated individual who wants to set a quit date and attempt to stop Six session group treatment – recommend quitting between second and third session – some may delay. Encourage the use of NRT or FDA approved medications with group support Inform primary therapist / psychiatrist

22. LAHL GROUP II: Session Outline 1.Making a Quit Plan 2.Preparing to Quit 3.Seeking Support While You Quit 4.Refusing Cigarettes & other triggers 5.Dealing with Setbacks 6.Celebrating Quitting and a Tobacco-Free Lifestyle

23. Preliminary Outcomes Approximately 12 members and 3 staff attending LAHL Group I meetings weekly 64 people have attended at least one LAHL Group I meeting 20 members have attended LAHL Group II 23 members have made quit attempts, 4 without relapse Approximately 425 carbon monoxide readings have been conducted for clubhouse members and staff

24. Year 1 Accomplishments Include: Establishing healthy living meetings Creating peer tobacco leaders Creating resources for members and staff with regard to health promotion and consequences of tobacco use. Genesis tracking members interested in tobacco cessation Tobacco cessation part of rehabilitation plan Genesis established an outdoor tobacco free area and held a ribbon cutting ceremony in conjunction with World No Tobacco Day Entire clubhouse grounds will be smoke free for the day for the Great American Smoke Out on November 19, 2009. Information regarding tobacco cessation activities is available via the clubhouse’s newsletter, brochures, the tv monitor and web site.

25. Ongoing Activities Continue with LAHL Group 1 and 2 Ongoing ATTOC Creating a Clubhouse Wellness/Health Promotion Toolkit Piloting a new health promotion and tobacco cessation training for clubhouses with Genesis Club How to integrate tobacco cessation activities into the clubhouse Lessons learned

26. Contact Information Colleen McKay, M.A., C.A.G.S. 508-856-8471 colleen.mckay@umassmed.edu The Program for Clubhouse Research Center for Mental Health Services Research Department of Psychiatry University of Massachusetts Medical School 55 Lake Avenue North Worcester, MA 01655