Abstract

Research has shown that psychologists are less likely to intervene for tobacco use than other risky health behaviors. The United States Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence (TTUD), provides evidence-based recommendations for clinicians to promote tobacco cessation and reduce the burden of tobacco-related illness. The purpose of this study was to examine the impact of a continuing education program (Providers Practice Prevention: Treating Tobacco Use and Dependence) designed to promote use of effective tobacco cessation strategies. Data concerning participants’ tobacco cessation knowledge, attitudes, and practice was collected prior to, immediately after, and one year following participation in the intervention. Participants included 75 licensed Kentucky psychologists. Interestingly, results showed that 2 out of every 3 participants had not previously heard of the TTUD guideline. Immediately after the intervention, participants expressed significantly more positive attitudes toward tobacco cessation, maintained more tobacco cessation knowledge, and reported greater intentions to integrate tobacco cessation strategies into their clinical practice. Although behavioral intentions reported immediately following the intervention did not completely translate into behavior change, results showed significant increases in the use of tobacco cessation strategies compared to baseline. Overall, the program appeared to promote the integration of the TTUD recommendations into the clinical practice of participating psychologists. To enhance the effects of future interventions, researchers/educators might consider incorporating follow-up information to help clinicians maintain their initial motivation and knowledge, while expanding their skills in treating tobacco dependence.

Introduction

Tobacco use is responsible for 30% of all cancer deaths in the United States and is the most preventable cause of cancer (American Cancer Society, 2004). Although 80% of smokers report no specific plan to quit (Norman, Velicer, Fava, & Prochaska, 2000), 70% express a desire to stop smoking at some point (Fiore et al., 2000). Notably, 44% of cigarettes are consumed by individuals with a mental health or substance use/abuse disorder (Lasser, 2000), yet only one previous study has explored the nicotine dependence (ND) treatment patterns of psychologists (i.e., Phillips & Brandon, 2004). Wetter et al. (1998) identified five reasons psychologists should be concerned with smoking cessation and integrating treatment of 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

Phillips and Brandon (2004) 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 offering/providing these services, even to willing patients.

• Fewer than 33% reported asking all of their adult and adolescent patients whether they use tobacco and advising patients who use tobacco to quit
  
• Almost half of participants reported assessing every patients’ willingness to quit using tobacco (47%)
  
• Less than 20% reported assisting with referrals or providing treatment
  
• Just over one-third indicated that they arranged tobacco cessation follow-up
  

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.

Purpose

The purpose of the current study was to examine the impact of a self-study continuing education program (PPP-TTUD) on:

• 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 designed to promote awareness of the recently published 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).

Procedure

Participants completed three parallel questionnaires regarding their knowledge, attitudes, and practices pertaining to treatment of tobacco use and dependence. Questionnaires were completed prior to (PRE), immediately following (POST), and one year after program completion (FOL).

Measures

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

Participants

Total participants: N = 75
Complete surveys: N = 50

Females:
Total: 40 (53%)
Complete: 24 (48%)

Ph.D.:
Total: 55 (73%)
Complete: 39 (78%)

Patient Population - total:
Urban–25 (33%)
Suburban–23 (31%)

Patient Population - complete:
Urban–17 (34%)
Suburban–16 (32%)

• The average number of years in practice was 14.28 (SD = 10.49) and ranged from 1 to 35 years in practice.
  
• There were no significant differences between participants who provided complete data and participants who only provided pre and post data on any of the background variables .
  

Results

Objective Knowledge (on a scale of 1-8 correct)
Pre-test: 5.37
Post-test: 6.78
Follow-up: 4.94
F(2,96) = 20.73, p<.001, η2p = .30

Subjective knowledge (on a scale of 1-not at all comfortable to 4-very comfortable)
Pre-test: 2.43
Post-test: 3.67
Follow-up: 3.11
F(2,90) = 31.49, p<.001, η2p = .41

Attitudes Towards Tobacco Cessation (on a scale of 1-strongly disagree to 5-strongly agree)
Self-Efficacy
Pre-test: 2.6
Post-test: 3.2
Follow-up: 3.2
F(2,94) = 25.00, p<.001, η2p = .35

Response Efficacy
Pre-test: 2.5
Post-test: 3.6
Follow-up: 2.9
F(2,92) = 27.17, p<.001, η2p = .37

Behavior Change - The 5 A’s (on a scale of 1-never to 5-always)
Ask
Pre-test: 3.06
Post-test: 4.04
Follow-up: 3.38

Advise
Pre-test: 3.2
Post-test: 4.2
Follow-up: 3.31

Assess
Pre-test: 2.5
Post-test: 4.6
Follow-up: 3.2

• Participants reported on six methods of ASSISTING patients with tobacco cessation. Each variable changed significantly from PRE to POST; yet only two of the variables remained significantly different when comparing PRE and FOL data. After the intervention, participants reportedly provided counseling and problem-solving strategies as well as educational materials significantly more often than at baseline.
  
• Participants reported on five methods of ARRANGING tobacco cessation follow-up. Results revealed that each variable except staff visit changed significantly from PRE to POST; yet none of the variables remained different when PRE and FOL were compared.
  

Conclusions

• Immediately after the intervention, results showed an increase in knowledge, more positive attitudes, and greater intentions regarding treatment of tobacco use and dependence.
  
• However, many of the changes in knowledge, attitudes, and behavior were not maintained at one-year follow-up.
  
• It is likely that additional intervention components (maintenance programs) are needed to consolidate changes and bolster the positive initial effects of this program.
  

Limitations

• Non-randomized intervention study (no control group)
  
• Sample limited to doctoral-level clinicians in Kentucky
  

References

American Cancer Society. (2004). Cancer Facts & Figures, 2004. Atlanta, GA: American Cancer Society, Inc.

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.

Lasser, K., Boyd, W.J., Woolhandler, S., Himmelstein, D., McCormick, D., & Bor, D.H. (2000). Smoking and mental illness: A population-based prevalence study. Journal of the American Medical Association, 284, 2606-2610.

Norman, G. J., Velicer, W. F., Fava, J. L., & Prochaska, J. O. (2000). Cluster subtypes within stage of change in a representative sample of smokers. Addictive Behaviors, 25, 183-204.

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.