Statistics show that adults with a behavioral health disorder (i.e., a mental health disorder and/or a substance use disorder) disproportionately have higher smoking rates, find it harder to quit tobacco use and face disparities in treatment. But with about 70 percent of tobacco users seeing a physician each year, family physicians are uniquely positioned to help these patients.
The team at West Virginia Health Right Inc. in Charleston, W.Va., includes (from left) executive director Angie Settle, D.N.P.; Office Champion Brenda Parker; clinical coordinator Rhonda Francis; and deputy director Ann Hyre.
The Academy created its Multi-State Office Champions Behavioral Health Tobacco Cessation project to reach populations of patients dependent on tobacco who also had behavioral and mental health comorbidities. The project, which ran from April to July of this year, targeted the two states with the highest adult smoking prevalences: Tennessee (24.3 percent) and West Virginia (27.3 percent).
The program was supported by the Smoking Cessation Leadership Center at the University of California, San Francisco.
One of the deliverables for this project was to develop an Office Champions Tobacco Cessation Behavioral Health Fact Sheet, which has been converted into an online tool.
Tobacco Cessation Behavioral Health Online Tool
The tobacco cessation behavioral online tool offers information on the challenges of quitting, medications affected by smoking and smoking cessation, the family physician's role in helping smokers with behavioral health disorders quit, and recommended interventions.
- The Academy's Multi-State Office Champions Behavioral Health Tobacco Cessation project targeted the two states with the highest adult smoking prevalence: Tennessee and West Virginia.
- The project, which ran from April to July, was supported by the Smoking Cessation Leadership Center at the University of California, San Francisco.
- One of the deliverables for this project was to develop an Office Champions Tobacco Cessation Behavioral Health Fact Sheet, which was made into an online tool.
In addition, the resource describes the importance of integrating behavioral health care into primary care to help patients quit smoking and offers links to AAFP documents on treating tobacco dependence, including through group visits.
The online tool also offers information on counseling and behavioral therapy and describes the importance of motivational interviewing and the "Five R's" (relevance, risk, rewards, roadblocks, repetition) system to support family physicians' tobacco control efforts.
Finally, the resource lists the FDA-approved medications for patients trying to quit smoking.
The practices in Tennessee and West Virginia that participated in the Multi-State Office Champions Behavioral Health Tobacco Cessation project used these resources to better control their patients' tobacco use.
Success Stories From Participants
West Virginia Health Right Inc. in Charleston, W.Va., is an urban nonprofit clinic that provides health care at no cost to 15,800 uninsured or underinsured low-income residents from 34 South Central counties. The staff is made up of 300 volunteer medical professionals, including family physicians and four family nurse practitioners, two of whom work full time and two who work part time.
Angie Settle, D.N.P., executive director and CEO for West Virginia Health Right, told AAFP News that although the clinic already had an excellent program in place to identify and help patients quit tobacco use, after completing the Office Champions practice evaluations, the clinic implemented several improvements to strengthen and expand its tobacco cessation protocols.
"One of the major areas that needed improvement was communication among all staff that a patient is a tobacco user and that every staff member needed to reinforce 'Quit Tobacco, Every Patient, Every Visit,'" she said.
Before participating in the Office Champions program, when the front office personnel identified a patient as a tobacco user, that information was included in the patient's electronic health record (EHR), but not whether the health care professional who saw that patient addressed the tobacco issue, said Settle.
After completing the Office Champions program, West Virginia Health Right now requires clinicians to document in the EHR that the patient was counseled on the importance of quitting tobacco use.
"Finally, for any patient who requires extra motivational help, all staff now refer that patient to the Office Champion for more intensive assistance," she said.
Settle said she'd recommend the Office Champions program to other medical practices because it provides a step-by-step review of quitting tobacco protocols, best practices and resources that are easily implemented.
Patient Centered Physician's Care P.C. is a solo family medicine practice in Jackson, Tenn., that uses a direct primary care model. Estimated tobacco use in the surrounding county is 25 percent, and the practice estimates 15 percent of its patient panel uses tobacco.
Practice owner Kimberly Howerton, M.D., who has 1.5 full-time equivalent (FTE) nonphysician staff helping her serve patients, told AAFP News that participating in the Office Champions program has led the practice to address tobacco prevention and cessation with every patient at every visit, whereas before, she addressed tobacco use periodically. Also, her medical assistant now includes tobacco use as a vital sign.
A huge plus, according to Howerton: Participating in the program was fairly effortless.
The University of Tennessee College of Medicine Chattanooga Family Medicine Residency team participating in the Office Champions project includes (from left) Michael Shepherd, M.D.; Catrice Walker, L.P.N.; X-ray technician Annie Campbell; office manager Renae Keef; Sheri Carter, L.P.N.; and Meagan Hewitt, L.P.N.
"At first, I was concerned the study might involve a significant amount of administrative work on our part, but it didn't," she said. "It just put the tools in our hands. We started using parts of our electronic records that we had never used before and we were able to easily provide patients the assistance that they needed. I would do it again."
Tug River Catterson Health Center is a small rural practice in Pineville, W.Va., that counts on one full-time and one part-time physician, as well as 4.5 FTE nonphysician staff, to support its 1,587 active patients.
Joanna Bailey, M.D., told AAFP News that her office has always done a great job of identifying smokers, but the group learned through the initial chart review that it was not doing so well in offering and documenting intervention for active tobacco users.
"Our intervention involved having the nurses mark the encounter form with a green checkmark if the patient was an active tobacco user and willing to discuss quitting," she said. "This triggered the provider to offer intervention.
"We also put 'Quit Line' cards and pamphlets in the area near the exam rooms where providers could easily give them to patients."
Health care professionals now are beginning to put "nicotine dependence" on the problem list more often and are generally more aware of whether a patient smokes or not, Bailey said. "Overall, we really think this project helped improve how we treat tobacco use in our office."
The University of Tennessee College of Medicine Chattanooga Family Medicine Residency is a 27-physician practice (including residents and staff physicians) that serves about 7,000 active patients. The estimated prevalence of tobacco use in the surrounding county is 22.6 percent, with an estimated 28 percent prevalence in the practice itself.
Michael Shepherd, M.D., told AAFP News the residency practice came into the Office Champions project rather late, but the AAFP made the transition an easy one with all of the information it provided.
The program helped the residency successfully pinpoint patients who would benefit from smoking cessation practices, he said. "I also saw improvement with the physicians providing cessation tools to patients who were interested in quitting," Shepherd added. "We have now implemented regular smoking assessments on all patients."
"I would recommend other practices participate," he said. "This was a very helpful, nonconfusing way to promote better health with our patients."
Related AAFP News Coverage
Academy Launches Tobacco and Nicotine Toolkit for Members
Effort is Part of Overarching Healthy Interventions Program
More From AAFP
Ask and Act Tobacco Cessation Program
Smoking Cessation Leadership Center (SCLC): The Tobacco Epidemic Among People With Behavioral Health Disorders, 2015(smokingcessationleadership.ucsf.edu)