Incorporating Tobacco Cessation Activities in a Psychosocial Rehabilitation Clubhouse

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 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.

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: 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

10. 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.

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

12. 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.

13. 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.

14. 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

15. 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.

16. 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

17. 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!

18. 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.

19. 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

20. LAHL GROUP II: Session Outline • Making a Quit Plan • Preparing to Quit • Seeking Support While You Quit • Refusing Cigarettes & other triggers • Dealing with Setbacks • Celebrating Quitting and a Tobacco-Free Lifestyle

21. 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

22. 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.

23. 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

24. 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