Web-Based Training May Increase Residents’ Treatment of Patients for Tobacco Use

Psychiatry residents were more likely to advise patients on tobacco use disorder and provide treatment after completing an online training course, according to a study published in Psychiatric Services in Advance.

Though tobacco use accounts for half of all deaths of individuals with mental illness or substance use disorder, “educational opportunities for psychiatrists and residents remain limited,” wrote Jill Williams, M.D., of Rutgers-Robert Wood Johnson Medical School in New Jersey and colleagues. The data suggest “that an online training opportunity, especially early in residency, may increase knowledge about tobacco use disorder and, more importantly, increase the frequency of behaviors likely to result in reduced tobacco use in the vulnerable populations these residents will treat,” they noted.

U.S. psychiatry residency program directors provided the researchers with the email addresses of current psychiatry residents; participation was not required. A total of 199 residents completed surveys that evaluated their attitudes toward tobacco treatment practices (such as monitoring patients' progress in attempting to quit and prescribing tobacco treatment medications) and estimated how frequently they applied such practices.

The residents then viewed three one-hour webinars on tobacco treatment, which covered topics such as the prevalence and consequences of tobacco use disorder among individuals with behavioral health conditions, as well as counseling strategies and pharmacological treatments. Of the 152 participants who completed the online course, 89 completed a follow-up assessment three months later.

There was “considerable variability” in residents’ ratings of tobacco treatment practices at baseline, the authors reported. Asking patients about their smoking status was the most highly reported treatment practice, with 47% of residents always asking, and 44% usually asking. Others, such as prescribing tobacco treatment medications or arranging follow-up visits to address smoking, were reported less frequently.

In the three-month follow-up, however, “[r]esidents reported a significant increase in their use of nine of the 12 tobacco treatment practices,” Williams and colleagues wrote. The findings include the following:

• Residents who said they always assess patients’ willingness to quit smoking increased from 15% at baseline to 23% at follow-up.
• Residents who said they usually refer patients who smoke to others for appropriate cessation treatment increased from 18% to 36%.
• Residents who said they usually refer smokers to a telephone cessation service like Quitline increased from 8% to 19%.

The authors found that residents who were earlier in their training (first- and second-year residents) were more likely to change their tobacco treatment practices than third- through fifth-year residents. “This finding may imply that educational efforts are more effective before residents have solidified their practice patterns, even though junior residents have less control over their own practice.”

For related information, see the Psychiatric News article “Psychiatrists Hold Key for Helping Patients Quit Tobacco.”

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Psychiatrists Can Do More to Help Patients Quit Smoking, Addiction Experts Say

Several medications are proven to help people stop smoking, but few patients with tobacco use disorder are being offered them, according to addiction experts at APA’s IPS: The Mental Health Services Conference in New York.

Despite the higher rates of smoking by people with mental illness compared with those without mental illness, only a quarter of facilities that treat patients with substance use disorders in the United States offer nicotine replacement therapy or medication treatment, and two-thirds allow tobacco use on their grounds, explained session chair Michael Brus, M.D., a clinical instructor of psychiatry at Icahn School of Medicine at Mount Sinai, during the session “The Deadliest Drug Epidemic: How Psychiatrists and the Media Miss the Boat on Tobacco Addiction, and What to Do About It.” Brus called for psychiatrists to do more to address tobacco use in this population.

To help patients successfully quit tobacco, Jill Williams, M.D., director of the Division of Addiction Psychiatry at the Rutgers University-Robert Wood Johnson Medical School, said psychiatrists should regularly ask patients about their tobacco use, and if they do use tobacco, advise patients on the risks of such use and refer them to treatment such as behavioral counseling.

Psychiatrists should also strongly consider prescribing smoking cessation medications, including varenicline, which is underused despite strong evidence of safety and efficacy.

Brus highlighted a 2016 study known as EAGLES that found varenicline to be superior to bupropion and the nicotine patch in helping smokers achieve abstinence (the study did not show a significant increase in adverse psychiatric events in patients taking varenicline compared with those with nicotine patch or placebo). Yet in the three years since that study, prescription rates of varenicline have ticked up only marginally, Brus said.

Williams highlighted another study that found that varenicline could promote smoking abstinence even in patients whose initial goal was only to reduce their smoking levels. “There’s also evidence that varenicline can lessen dependence and reduce withdrawal symptoms, so prescribing this medication can be a useful harm-reduction strategy even in people not looking to quit,” she said.

For psychiatrists who may still have concerns with varenicline, Brus and Williams pointed out that combination nicotine replacement (combining a long-acting patch with rapid-acting lozenges or gum) has been shown to be as effective as varenicline when combined with counseling. The current data are inconclusive about whether a combination of varenicline plus nicotine replacement therapy promotes better abstinence than either treatment alone. There is emerging evidence that varenicline plus bupropion may elevate quit rates, but more research is needed.

For related information, see the Psychiatric News article “Psychiatrists Hold Key for Helping Patients Quit Tobacco” and the Psychiatric Services article “Low-Burden Strategies to Promote Smoking Cessation Treatment Among Patients With Serious Mental Illness.”

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Addiction Specialist Sounds 'Wake-Up Call' to Psychiatrists About Smoking

Psychiatrists should be providing smoking cessation treatment to all tobacco users, said psychiatrist Jill Williams, M.D., at APA’s  2014 Institute on Psychiatric Services.

Williams, a professor of psychiatry and director of the Division of Addiction Psychiatry at the Robert Wood Johnson School of Medicine, told attendees that the broad public health success that has been achieved with regard to decreasing smoking in the general population has not been extended to those with mental illness—especially serious mental illness. “Smoking is the leading cause of death in people with mental illness or addiction,” she said, citing statistics showing that 50 percent of deaths among people with schizophrenia, bipolar disorder, and depression are attributable to smoking, and that persons with mental illness or addiction purchase and consume up to 44 percent of all cigarettes in the United States.

Moreover, tobacco use disorder is a diagnosable condition in DSM-5. Yet psychiatrists have largely not treated their patients for smoking for a variety of reasons—including a prevalent belief that quitting smoking may actually interfere with treatment of mental illness. But Williams presented evidence showing that smoking cessation has no negative impact on treatment and does not jeopardize recovery from addiction to other substances. And she cited her own 2012 study in the Journal of Clinical Psychiatry demonstrating the safety and efficacy of varenicline in patients with schizophrenia and schizoaffective disorder.

“We as psychiatrists should provide treatment to all smokers,” Williams said. “We should intervene more during periods of temporary abstinence—we detox for other substances; we should detox for this substance. We should promote education and provide leadership to change [smoking] policies at treatment centers. And we should provide national leadership and advocate as physicians.”  

For more information, see the Psychiatric News article "Smoking Cessation for Patients Called an Urgent Priority."

Training Mental Health Clinicians Boosts Tobacco Treatment for Patients, Study Finds

Training a range of mental health clinicians to deliver tobacco treatment services can increase use of such services and boost the patients’ willingness to quit smoking, according to a new study published in Psychiatric Services in Advance.

“Smoking rates among individuals with a mental illness or substance use disorder are at least double those of the general population,” said Jill Williams, M.D., a professor and director of the Division of Addiction Psychiatry at the Robert Wood Johnson Medical School, and colleagues.

The researchers recruited 20 clinicians, including 13 psychiatrists, and gave then a two-day training session on assessment and treatment of smokers. The curriculum covered behavioral and pharmacological treatments, how to help less-motivated smokers, and how to manage complex cases. Patient charts from the clinicians’ caseload were reviewed before and after the training. After the training, more patients were advised to quit by the participating clinicians (9% before versus 36% after training), more developed treatment plans for quitting (20% versus 60%), and more patients were informed about nicotine replacement therapy (10% versus 31%).

Despite this improvement, more could be done for these patients, concluded Williams and colleagues. “Strategies beyond training may be needed to enhance [smoking-cessation] prescribing by these practitioners,” they suggested.

For more in Psychiatric News about the link between smoking and mental illness, see the article “Smoking Cessation for Patients Called an Urgent Priority.”

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Electronic Cigarettes May Be Gateway to Traditional Smoking Among Youth

Electronic cigarettes (e-cigarettes) are marketed to help people quit smoking regular cigarettes and subside nicotine addiction, but a recent study published in JAMA Pediatrics demonstrates that it may be doing the opposite in adolescents.

Researchers from the Center for Tobacco Control Research an Education at the University of California San Francisco conducted the first analysis of the relationship between e-cigarette use and conventional smoking among adolescents in the United States. Data were gathered from the National Tobacco Youth Survey, which included nearly 40,000 middle- and high-school-aged youth. The analysis revealed that e-cigarette use among students doubled between 2011 and 2012, from 3.1 percent to 6.5 percent. In addition, use of e-cigarettes was associated with increased risk to begin conventional cigarette smoking.

Jill Williams, M.D., director of the Division of Addiction Psychiatry at Rutgers University Robert Wood Johnson Medical School, who was not involved with the study, expressed to Psychiatric News that these findings are concerning since the rates of conventional smoking had been declining to record lows. 

“Behavioral health professionals, including psychiatrists, should do more to assess and treat their adolescent and adult patients for tobacco dependence, just as they would for any other substance use disorder," said Williams. "The tobacco industry has a history of marketing 'safer' products to the public, and we should remain skeptical until this is proven with scientific information.” 

Williams concluded that if these products continue to go unregulated, the popularity of e-cigarettes has the potential to undo decades of progress in denormalizing tobacco use and making it more attractive to those with nicotine addiction.

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