Abstract

Research shows that assessment of tobacco use and dependence is not a high priority for most psychologists. However, tobacco use is the most preventable cause of illness in the United States. Additionally, 44% of cigarettes are consumed by individuals with a mental health or substance use disorder, presenting an opportunity to reduce tobacco-related illnesses among individuals who seek mental health services. The purpose of this investigation was to assess the impact of a self-study continuing education program, Providers Practicing Prevention: Treating Tobacco Use and Dependence (TTUD), on master’s level and newly licensed psychologists in Kentucky. Most of the 33 participants were female (67%) and practiced in a rural setting (53%). Participants ranged greatly in experience (1-45 years). Questionnaires were administered prior to program participation and after program completion. The questionnaires posed parallel questions involving knowledge, attitudes, and clinical practices regarding tobacco cessation. Results indicated that participants’ objective and subjective knowledge regarding TTUD guidelines and tobacco cessation information increased significantly post-intervention. Participants also reported an increase in selfefficacy as well as efficacy beliefs concerning tobacco cessation interventions. Finally, participants reported increased intentions to integrate TTUD recommendations into their clinical practice, including patient identification, advising tobacco-using patients to quit, assessing motivation to quit, assisting in the development cessation plans; and arranging additional intervention. Overall, the study demonstrated that the continuing education program had a favorable impact on tobacco cessation-related knowledge, attitudes, and intentions to integrate tobacco cessation strategies into routine practice.

Introduction

Kentucky has the highest rate of adult smoking at 30.8% (Centers for Disease Control and Prevention, 2003b). Approximately 40% of Kentucky high-school students smoke, and Kentucky leads the nation in the number of women who smoke during pregnancy. Although physicians have traditionally provided the majority of tobacco cessation interventions, Wetter et al. (1998) identified five reasons psychologists should be concerned with tobacco cessation and integrate treatment of nicotine dependence (ND) into clinical practice.

1. ND is considered a mental disorder
2. ND frequently accompanies other mental health disorders
3. Consumer demand for ND treatment is substantial
4. Psychologists have skills to evaluate ND treatment programs
5. ND causes significant morbidity and mortality

In 2004, Phillips and Brandon surveyed 256 practicing psychologists regarding their tobacco cessation practices and showed that psychologists are less likely to intervene for tobacco use and nicotine dependence than other risky health behaviors. Despite reporting adequate training in smoking cessation strategies, very few participating psychologists actually reported providing these services, even to willing patients. Overall, participants reported a very low level of adherence to clinical practice guidelines for tobacco cessation, suggesting a need for more training in this area.

Miller et al. (2005), utilizing the PPP-TTUD program with psychologists in Kentucky, determined that fewer than two out of three licensed psychologists had ever heard of the guideline. In addition, the authors demonstrated that the introduction of the TTUD guideline could positively impact psychologists’ knowledge, attitudes, and behaviors regarding tobacco cessation practices.

Purpose

The purpose of the current study was to examine the impact of a self-study continuing education program (PPP-TTUD) on master’s level clinicians and newly licensed psychologists.

Items specifically examined were:

• Knowledge of TTUD clinical practice guidelines
  
• Attitudes toward tobacco use and cessation
  
• Practice of effective tobacco cessation strategies
  

Method

Intervention

The PPP-TTUD program was developed to promote awareness of the Clinical Practice Guideline for treating tobacco use and dependence. The program was specifically designed for Kentucky health care providers, by providing Kentucky-specific data regarding tobacco use and dependence. The program included three major components: (1) a motivational videotape; (2) the Treating Tobacco Use and Dependence: Quick Reference Guide for Clinicians (Fiore et al., 2000b); and (3) a clinician’s tool kit. The 30 minute videotape, which included Kentucky health care providers as presenters, provided information, testimonials, and encouragement to incorporate tobacco cessation into clinical practice. The Quick Reference Guide for Clinicians (QRGC) is a publication of the United States Public Health Service (Fiore et al., 2000b) and is an abbreviated version of the Treating Tobacco Use and Dependence: Clinical Practice Guideline (Fiore et al., 2000a). The clinician’s tool kit included provider cessation aids, office tools, and patient education materials.

Procedure

Participants completed two parallel questionnaires regarding their knowledge, attitudes, and practices pertaining to treatment of tobacco use and dependence. Questionnaires were completed prior to (PRE) and immediately following (POST) the self-study program.

Measures

The survey included questions addressing:

1. attitudes toward TTUD guideline;
   
2. knowledge of TTUD guideline;
   
3. TTUD guideline practices (use of the 5 A’s) - Ask, Advise, Assess, Assist, Arrange
   
4. sociodemographic characteristics; and
   
5. program evaluation information.
   

Participants

Total (N = 33)

Female: 22 (67%)

M.A./M.S.: 24 (73%)

Patient Population
    Rural: 17 (53%)

The average number of years in practice was 13 (SD = 10.27) and ranged from 1 to 45 years in practice.

Results

Knowledge

Objective Knowledge (on a scale of 1-8 correct)
Pre: 5.12
Post: 7.12

Subjective Knowledge (on a scale of 1-4)
Pre: 2.36
Post: 3.55

Attitudes Towards Tobacco Cessation

Self-Efficacy (on a scale of 1-4)
Pre: 1.39
Post: 2.31

Response-Efficacy (on a scale of 1-4)
Pre: 2.82
Post: 2.91

• Objective knowledge increased significantly from PRE to POST t(32) = 6.78, p < .001.
  
• Subjective knowledge also increased significantly POST intervention t(32) = 7.40, p < .001.
  
• Results of paired t-tests showed significant change in clinicians’ perception of patient risk, t(30) = 3.86, p = .001.
  
• Clinicians’ cessation self-efficacy increased significantly post-intervention, t(31) = 6.66, p < .001;
  
• Clinicians’ belief that brief tobacco interventions for their patients were effective also significantly increased, t(31) = 7.96, p < .001.
  
• However, clinicians’ belief in the effectiveness of tobacco interventions for reducing morbidity/mortality (response efficacy) was unchanged, t(32) = 1.36, p = .184.
  
• Clinicians' significantly increased their intention to identify every patient for tobacco use from 52% to 90% (p = .002).
• Intentions to adopt the recommended 5 A’s (Ask, Advise, Assess, Assist, and Arrange) increased from PRE to POST. Ask, Advise, Assist, and Arrange all increased significantly (p’s < .05).
  

Behavior Change - The 5 A’s (scale of 1-rarely to 5-always)

Ask
Pre: 3.00
Post: 4.19

Advise
Pre: 2.97
Post: 4.23

Assess
Pre: 3.52
Post: 3.9

Assist
Pre: 3.03
Post: 4.52

Arrange
Pre: 3.61
Post: 4.61

Conclusions

• Results demonstrated a change in clinicians’ knowledge (objective and subjective), attitudes (self-efficacy), and intention to follow the clinical practice guideline.
• From PRE to POST, clinicians nearly doubled in their intention to identify tobacco using patients.
  
• Future research using Master’s level clinicians as cessation interventionists is recommended.
  

Limitations

• Non-randomized intervention study (no control group)
  
• Small sample size (N = 33)
  

References

Center for Disease Control and Prevention. (2003). State-specific prevalence of current cigarette smoking among adults – United States, 2002, MMWR, 52, 1277-1300.

Fiore, M. C., Bailey, W. C., J., C. S., Dorfman, S. F., Goldstein, M. G., Gritz, E. R., et al. (2000a). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service.

Fiore, M. C., Bailey, W. C., J., C. S., Dorfman, S. F., Goldstein, M. G., Gritz, E. R., et al. (2000b). Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians. Rockville, MD: United States Department of Health and Human Services. Public Health Service.

Miller, B.F., Lotz, C.L., Worth, C., Studts, J.L., & Sorrell, C. (2005). Providers Practice Prevention – Treating Tobacco Use and Dependence Program for psychologists: One-year follow-up data. Poster presented at the Society of Behavioral Medicine, Boston, Massachusetts.

Phillips, K.M. & Brandon, T.H. (2004). Do psychologists adhere to the Clinical Practice Guidelines for tobacco cessation? A survey of practitioners. Professional Psychology - Research and Practice, 35, 281-285.

Wetter, D. W., Fiore, M. C., Gritz, E. R., Lando, H. A., Stitzer, M. L., Hasselblad, V., et al. (1998). The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline: Findings and implications for psychologists. American Psychologist, 53, 657-669.