Peer-to-Peer Tobacco Program: Services for Behavioral Health Consumers
To assist individuals to lead meaningful lives, treatment settings need to promote behaviors that lead to health and wellness. The Peer-to-Peer Tobacco Dependence Recovery Program does so by filling a critical gap in behavioral healthcare settings- tobacco dependence services for persons with substance abuse or mental health disorders. Although many barriers to tobacco cessation services in behavioral settings remain (Morris et al., 2009), integration of tobacco treatment into the mainstream of substance abuse and mental health treatment is rapidly becoming a nationwide best practice (Schroeder, 2007). The overarching goals of the program are to 1) Offer peer tobacco recovery services to persons served in behavioral healthcare settings who express an interest in reducing or quitting their tobacco use, 2) Evaluate the effectiveness of the program, and 3) Create a program that is sustainable.
The program strives to improve health and wellness outcomes among the up to 80 percent of individuals in behavioral health treatment interested in quitting smoking (Prochaska et al., 2004). Through tailored holistic services for tobacco dependence, the program promotes recovery. The program offers emotional and informational support for tobacco dependence recovery through motivational engagement strategies, peer-led support groups, community referrals, and educational activities. Peers create new services (e.g., groups), and also increase utilization of existing resources like 12-step groups, faith-based programs, and quitlines which provide no-cost telephonic counseling and often nicotine replacement therapy.
The Peer-to-Peer Tobacco Dependence Recovery Program uses an “embedded” model which we have found to be sustainable across many different types of organizations. In this model, we look for programs that already have peer specialists on staff or as volunteers, or have the capacity to hire future peers. We then train peer specialists to integrate tobacco cessation and wellness services into their existing roles and responsibilities. The Behavioral Health & Wellness Center provides a 2-day site start-up training session for peer specialists. After the training, peers are encouraged to start services. We provide ongoing technical assistance through a national peer listserv, regular telephonic forums, and web-based continuing education modules. It is important to note that this is a train-the-trainer model. Peers who have been through the 2-day training are provided all the materials necessary to then train their colleagues.
The program is currently active in over 28 states throughout the US. A variety of sites organizations including the Veterans Administration, mental health and addictions treatment agencies, and advocacy groups have implemented the program. Through the support of the Smoking Cessation Leadership Center at the University of California San Francisco, we are doing a multi-site evaluation to explore smoking reduction and cessation, functioning, satisfaction, and program sustainability.
Peer-to-Peer Tobacco Dependence Recovery Program Services
Only 4.5% of Colorado smokers are able to quit smoking without assistance (Tobacco Program Evaluation Group, 2007; Amendment 35 Program Evaluation Group, June, 2009). Peer specialists are trained to provide the below range of outpatient services which will lead to greater tobacco reduction and cessation rates among persons served. The programs’ primary services are highlighted below.
Education and Awareness Building
Through education and awareness building, peer specialists are empowered to become tobacco dependence recovery and wellness champions within their treatment agencies. A large part of their role as the peer specialist is to educate not only clients but also providers and staff on the issues of tobacco dependence, related health effects, and the unique challenges persons with behavioral health disorders face when attempting to reduce or quit tobacco use. Peer specialists provide information and support by conducting in-service educational events with center clients, presenting at provider and staff meetings, running wellness booths at social and organizational events, and even advocating for stronger organizational policies regarding tobacco consumption (e.g., smoke-free campuses). Peers’ goals are not only to educate, but to elevate the importance of tobacco dependence recovery within their organizations.
One-on-One Motivational Interview
Through motivational interviewing, the peer specialists conduct individual enhancement sessions in a private office using a scripted interview. To build motivational readiness for change, short interviews provide education on the health effects of smoking with immediate biological feedback using a portable hand-held carbon monoxide (CO) monitor. The dangers of carbon monoxide are explained to the client and their exhaled carbon monoxide level is taken. Peer specialists then assist clients to determine the amount of money spent on tobacco every day, week, month, year, and 5 years. The client and peer specialist work together to brainstorm other ways that money could be spent and the specialist helps the client to set financial goals using the money saved by quitting smoking. Finally, the specialist provides resources and service referrals for tobacco dependence treatment. The motivational interviews serve as a referral mechanism to peer support groups, as well as other community resources (i.e. state quitline, and health providers for cessation medications).
Tobacco Dependence Support Group
Peer specialists run weekly tobacco dependence support groups. The curriculum was designed by UCD specifically for persons with behavioral health disorders and was based on extensive review of the knowledge base and expert opinion for how best to intervene with persons with substance abuse and mental health disorders (CHOICES, 2004; American Legacy Foundation, 2006; Steinberg, 2004).
The group provides emotional, informational, and social support and functions in a drop-in capacity; clients are able to join the group at any time and attend as many sessions as necessary for their own recovery process. Educational handouts, group discussion, role playing, and activities are incorporated into the lesson plans. The support group provides wellness education; stress management and behavior change techniques; emotional support around tobacco dependence recovery; and allows clients to build tobacco-free social networks. The peer specialists are encouraged to share their own tobacco dependence recovery process in order to lead by example throughout the group. The aim is to provide a supportive environment in which peer specialists assist to identify and alleviate problems before they derail individual recovery efforts.
When clients are ready to set a quit date, the peer specialist will work with them to provide support through the group and through linkages to providers for cessation medications. However, setting a quit date is not mandated, as the group structure respects client diversity and honors different timelines and routes to recovery. After clients have quit using tobacco, they are invited to continue to attend group for additional support, as well as to provide additional mentoring to others in the recovery process. The group has six cycling sessions:
Session A: Healthy Behaviors- The objective of this session is to learn about living a healthy lifestyle and discover ways to make healthier choices. It provides general health and wellness education. The peer specialists review habits for a Healthy Lifestyle (including sleep, diet, exercise, tobacco cessation etc.). Clients participate in a group discussion regarding ways to incorporate physical activity and exercise into daily routines and perform a structured exercise learning to make healthier food choices. Finally, the peer specialist leads the group in a discussion about the health effects of smoking and of quitting and introduces tobacco cessation as an important step toward a healthier lifestyle.
Session B: The Truth about Tobacco- The objective of this session is to further discuss tobacco cessation or reduction as a step toward healthier living. Clients are educated about the chemicals and toxins found in tobacco smoke. The peer specialist leads an activity reviewing common myths and facts about smoking. The clients participate in an exercise to develop their personal reasons to continue tobacco use and reasons to quit. This activity allows tobacco users to recognize personal barriers to and motivations for tobacco dependence recovery. Finally, clients develop a list of their top 5 reasons to quit using tobacco.
Session C: Changing Behaviors- The objective of this session is to help clients recognize patterns of tobacco use and discover ways to change behaviors. Clients participate in an exercise to identify tobacco use triggers by reviewing their reasons for and key times of use. The peer specialist then leads a discussion regarding potential replacement behaviors. Clients participate in another exercise to discover enjoyable activities that do not involve tobacco use and are encouraged to start incorporating more of these activities into weekly routines.
Session D: Coping with Cravings- The objective of this session is to review cravings and determine methods for coping with cravings. Clients are educated about nicotine and nicotine addiction and review the physical and behavioral addictive properties. The peer specialists give clients a tool for raising craving awareness by scoring cravings on a 10-point scale. The group then participates in a discussion regarding healthy ways to cope with cravings and the specialist provides education on available medications to help nicotine withdrawal.
Session E: Managing Stress- The objective of this session is to give clients additional stress management tools, other than tobacco use. Clients discuss stress and current management techniques. The peer specialist then leads an exercise encouraging clients to think of stressful situations in which they used tobacco, and develop alternative techniques to managing those situations. Finally, the peer specialist instructs clients in a deep breathing exercise and encourages clients to start practicing deep breathing to help manage stress.
Session F: Planning Ahead- The objective of this session is prepare clients for potential future relapse situations and discuss the importance of planning ahead for high risk situations, even before a quit attempt is made. The peer specialist instructs clients in a visualization activity to picture life as a non-smoking. This activity helps clients identify their recovery goals and vision. The group then participates in a discussion regarding difficult situations and developing coping strategies. Then the specialist leads the group in a role-playing exercise to practice “saying no” when tobacco is offered in social situations. Clients are encouraged to start employing these strategies, even prior to making a quit attempt.
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