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 ResearchDepartment of Psychiatry

University of Massachusetts Medical School

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.

Health Promotion Activities Currently Provided by Clubhouses1

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.

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

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

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 environmentMembers are encouraged to participate in all

aspects of clubhouse operationsClubhouses are typically open 365 days a year.

Basic Clubhouse Components

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

Genesis Club

Free standing clubhouse established in 1988ICCD training center120 members per dayActive monthly membership of 300Membership: 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.

Genesis Club: Extent of Tobacco Use Among Members

82% of members (N=114) said they endorse smoking related behaviorsMany members (49%) want support with reducing tobacco use38% want to quit using tobaccoOther members want support with relapse prevention

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.

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

ATTOC Goals and ActivitiesProgram level:

Short-term goals: ongoing education about the effects of smoking and tobacco use, Pilot and modify tobacco cessation interventions for the clubhouseLong-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.

Developed to help smokers at any motivational level to quitTraining 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 GuideConsumer’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.

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

Monthly Budget as a Percentage of Median Public Assistance Received*

FoodShelterMisc. Living Expenses

Cigarettes

*Source: Steinberg ML, Williams JM, Ziedonis DM. (2004). Financial Implications of Cigarette Use in Smokers with Schizophrenia. Tobacco Control, 13, 206.

Session 6: How Much Does Smoking Cost?

Tobacco companies only spend 6 cents to make a pack of cigarettes

Review how smoking is expensiveAverage 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 smokingIdentify other things that could do with the money saved

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

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.

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 supportInform primary therapist / psychiatrist

LAHL GROUP II: Session Outline

1. Making a Quit Plan 2. Preparing to Quit3. Seeking Support While You Quit 4. Refusing Cigarettes & other triggers 5. Dealing with Setbacks 6. Celebrating Quitting and a Tobacco-

Free Lifestyle

Preliminary Outcomes

Approximately 12 members and 3 staff attending LAHL Group I meetings weekly64 people have attended at least one LAHL Group I meeting20 members have attended LAHL Group II23 members have made quit attempts, 4 without relapseApproximately 425 carbon monoxide readings have been conducted for clubhouse members and staff

Year 1 Accomplishments Include:

Establishing healthy living meetingsCreating peer tobacco leadersCreating 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 planGenesis established an outdoor tobacco free area and held a ribbon cutting ceremony in conjunction with World No Tobacco DayEntire 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.

Ongoing Activities

Continue with LAHL Group 1 and 2Ongoing ATTOCCreating a Clubhouse Wellness/Health Promotion ToolkitPiloting a new health promotion and tobacco cessation training for clubhouses with Genesis Club

How to integrate tobacco cessation activities into the clubhouseLessons learned

Contact Information

Colleen McKay, M.A., C.A.G.S.508-856-8471 colleen.mckay@umassmed.edu

The Program for Clubhouse ResearchCenter for Mental Health Services ResearchDepartment of PsychiatryUniversity of Massachusetts Medical School55 Lake Avenue NorthWorcester, MA 01655