NaRCAD: Why, historically, have rates of tobacco use been higher in folks with serious mental illness (SMI)?  Why has there been resistance for clinicians to promote tobacco cessation for this group?

Mark: It’s a complicated issue.  There are risk factors that increase the rate of smoking in this group and these are coupled with obstacles to getting appropriate treatment.  People with SMI are overrepresented among populations that face social and environmental conditions that are typically associated with an increased prevalence of smoking – poverty, unemployment, limited education, etc.  Obstacles to quitting include limited availability of resources, lack of clinician involvement, and poor social/peer support.

NaRCAD: Agreed! What do these AD-focused, 1:1 visits between trained physician educators and psychiatric prescribers entail? 

Mark:  The visits are 20-30 minutes long and follow the typical detailing visit structure. Visits are conducted by me, a psychiatrist at MMHC, or Gail Levine, MD, an internist and the Medical Director of our primary care clinic. 

​We meet with the prescribers in their offices, and begin by asking open-ended questions to assess their needs and learn about their successes (and challenges) in addressing tobacco use with their patients. We celebrate successes and validate challenges, and then pivot to sharing evidence-based information and key messages that may help them address these issues with greater success. We conclude the visit by reviewing steps the prescriber can take to increase successful tobacco treatment, and provide a copy of our detail aid, along with a few high-yield references. 

NaRCAD: We enjoyed working on this important project with you, and we know how important great materials are in engaging clinicians to consider behavior change. ​That said, how have psychiatric prescribers been responding?

Mark: The response has been quite favorable.  It's been rewarding to sit down with colleagues and learn from their experience and expertise and to be able to offer some useful information about tobacco treatment and the Smoke Free Program.  The one-on-one detailing encounters, even as brief as they are, give us quality time with our colleagues to focus on their individual concerns and questions.  We probably get as much information as we give! 

NaRCAD: Two members of your team, yourself and Gail Levine, attended our AD Techniques Training in 2015 to prepare for this initiative. How has the training helped you provide this education to prescribers?

Mark: Your training gave us an in-depth immersion into the world of academic detailing, helping us understand theories and evidence and think about implementation issues.  Getting to practice detailing and getting feedback from experts in the field was invaluable, as was the ability to talk with people from around the country who are working on similar projects.  NaRCAD's training is incredibly worthwhile – it was compact, comprehensive, and helped us acquire the needed skills to implement this project successfully.

Biography. Mark Viron, MD is an adult psychiatrist and Director of Health Home Services at the Department of Mental Health’s Massachusetts Mental Health Center (MMHC) in Boston and an Assistant Professor at Harvard Medical School.   He specializes in the treatment of psychotic disorders and the integration of primary and behavioral healthcare for people with serious mental illness. 

​He graduated from Tulane University School of Medicine and completed his psychiatry residency at the Massachusetts General Hospital/McLean Residency Program. He serves as an attending at MMHC’s partial hospital program, where he teaches and trains residents and medical students.  He is also the project director for two grant-funded initiatives that aim to enhance MMHC’s ability to provide integrated primary and behavioral healthcare. 

An Interview with Frank Leone on Treating Tobacco Dependence with AD

Dr. Leone directs Penn’s Comprehensive Smoking Treatment Program and was a former trainee with NaRCAD.

NaRCAD: Tell us a bit about yourself. How did you get into academic detailing?

Frank Leone: I’m a pulmonologist, and have been focused on the treatment of tobacco dependence for over 20 years.  In my early years, I had always been amazed at how infrequently my colleagues would approach the literature for solutions when facing this common problem in the clinic.  It seemed to me that they relied heavily on “common sense” approaches and techniques derived from misunderstandings, rather than consulting published guidelines and available standards.

I became interested in the behavioral economics of tobacco treatment decision-making in the clinic, and realized that traditional approaches to changing physician behavior might be inadequate for dealing with a cultural problem this well-entrenched.  We initially turned to NaRCAD for advice on Academic Detailing in 2011, and found the approach to have just the right potential to both meet the needs of the target audience, and allow us to deliver our message in a cost-effective and scalable way.

We were also given an opportunity to work with the Philadelphia Department of Public Health as they started up their efforts to influence the local provider culture around tobacco, and we’ve been “off to the races” working within our community, creating positive changes, ever since.

NaRCAD: What does your program focus on?  (What health issue does it address, and what clinician behavior are you seeking to change?)

Dr. Leone: Our Academic Detailing (AD) program focuses exclusively on tobacco dependence treatment.  As you can imagine, that problem cuts across a number of different audiences.  Our detailers work with physicians, psychologists, nurses, counselors and others to impact the rate at which tobacco treatment services are delivered in our area.  We use AD to address the limits in knowledge base around pharmacotherapy, as well as to shape the core assumptions about effectiveness of treatment in key patient populations (e.g. those with established lung disease or serious mental illness).

NaRCAD: Tell us about some of the growth you’ve seen and been a part of as it relates your program.

Dr. Leone: Our AD program has grown every year since its inception.  We started out focused on primary care physicians in underserved parts of Philadelphia.  From there, we expanded our target audience to include specialist physicians, nurses, and nurse practitioners.  Most recently, our audience has expanded to include behavioral health practitioners in both inpatient and outpatient settings.  Because of our success using AD to work with care providers from a variety of disciplines, we are currently exploring ways to extend AD principles to “system-wide” approaches to creating behavior change.

NaRCAD: What would you say are the greatest challenges you see in implementing this intervention?

Dr. Leone: Finding the right people to go into the field is imperative.  Over the years, I’ve been impressed that success during the AD interaction is less about what degree a person has, and more about the ability to be gently directive, while willing to truly listen.  Detailers need to be spontaneous and responsive to their audience, while at the same time keeping their inner eye on the target.  This is a skill that takes a little time and training to develop.  It sounds like it ought to be an easy thing to do, but we’ve found that an organized, logical, mentored approach to learning these skills is important to success.

NaRCAD: How about what works well? How do you know when you’ve been successful?

Dr. Leone: We always try to incorporate some sort of measurement tool into our AD projects.  It might be about knowledge, attitudes, or behaviors, but having a metric to gauge our impact is important feedback ensuring we stay on mark.  Our funders appreciate a concrete measure of change as well.

If I could figure out how to capture this, my favorite measure would measure the “A-ha!” moments that happen so often within the audience.  I love the look of epiphany in the clinician’s eye when a detailer has found a way to make the information relevant and transformative.  That’s when I know we’re really making change for the long run.

NaRCAD: You attended our Academic Detailing Techniques Training a few years back. What are the most useful resources or information that you’re still using today?

Dr. Leone: Truthfully, the greatest resource has been the continuing relationship with the NaRCAD team.  On multiple occasions during the conception and start-up phases of our project, we were able to touch base with professionals who had a large collective experience in diverse disciplines to get some great tips and suggestions.

On one specific occasion, I remember sharing a written detailing piece with the NaRCAD team. We had developed it in hopes of getting some feedback.  Not only did we get great advice, but it was professional advice – complete with references, examples, resources, and connections to the theoretical basis for the suggestions.  To me, this is the kind of interaction that helps my team grow and learn over time.

NaRCAD:  What does future success look like for you?

Dr. Leone: In twenty years, when you go visit your doctor for your annual check-up, and you hear him or her say, “Of course tobacco dependence is a chronic illness of the brain for which there are a number of effective treatments.  It’s hard to believe we used to simply tell people to stop!” –then you’ll know we’ve done our job well.
 
Biography:
Dr. Leone received his medical degree from the University of Pittsburgh, School of Medicine, and completed his postgraduate training in both general internal medicine and pulmonary / critical care medicine at Thomas Jefferson University Hospital. He also received his masters degree in clinical epidemiology and biostatistics from the University of Pennsylvania School of Medicine. Dr. Leone directs Penn’s Comprehensive Smoking Treatment Program, a clinical program of the Penn Lung Center, located at both Penn Presbyterian Medical Center, and the Perelman Center for Advanced Medicine. The new program provides state-of-the-art and individualized treatment to smokers, including those with co-morbidities.

Dr. Leone’s scholarship focuses on investigating advanced treatment strategies for tobacco use disorder, and on testing educational strategies for improving the care of the tobacco dependant patient.  Dr. Leone is a member of several professional and scientific societies, including the Society for Research on Nicotine and Tobacco, the American College of Chest Physicians, and the American Thoracic Society.  He has served the Commonwealth of Pennsylvania as a legislative appointee to the Governor’s Tobacco Use Prevention and Cessation Advisory Committee since 2001. Dr. Leone has been invited to speak at numerous lectures on topics of smoking treatment and pulmonary medicine, and has been published in a variety of clinical and research journals. He is board certified in pulmonary and critical care medicine. Learn more and review related publications on the University of Pennsylvania’s site.

Read more: Behavioral Economic Insights into Physician Tobacco Treatment Decision-Making : Leone, Frank