A Powerful Intervention: Tobacco Treatment for People with Serious Mental Illness

An Interview with Mass Mental Health Center

Featuring Mark Viron, MD, adult psychiatrist & Director of Health Home Services at the Department of Mental Health’s Massachusetts Mental Health Center (MMHC) in Boston; Assistant Professor at Harvard Medical School.  

Tags: Materials Development, Mental Health, Smoking Cessation, Training

​NaRCAD:  We’re excited to talk about your program because it focuses on such an important population, and such a specific topic that’s been a focus of public health initiatives across the nation. Tell us about Massachusetts Mental Health Center (MMHC).

Mark Viron:  MMHC is a Department of Mental Health (DMH) community mental health center in Boston that has provided mental health services for over 100 years to people with chronic and persistent mental illness. Its ultimate goal is to help people maintain meaningful and productive lives in their community.  In 2013, to better address the significant unmet primary care needs of our patients, we launched the Wellness and Recovery Medicine (WaRM) Center.  The WaRM Center offers co-located and integrated wellness and primary care services for all MMHC patients.

---

"People with serious mental illness die 25 years earlier than the general population, mostly from preventable [...] conditions."

NaRCAD:  Talk to us about the problem you’re addressing through the Smoke Free Program, which is funded in part through a Behavioral Health Grant from the Massachusetts Attorney General’s Office.

Mark: People with serious mental illness die 25 years earlier than the general population, mostly from preventable and treatable medical conditions such as cardiovascular disease.  More than 30% of people with SMI smoke cigarettes, and tobacco-related illnesses are significant contributors to this egregious mortality disparity.  Reducing smoking among people with SMI may be a powerful intervention for decreasing the mortality gap.

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.

​

​"Attitudes have changed among clinicians, but some harmful myths persist: 'They'll become [...] unstable if they quit.' "

Historically, smoking cessation treatments have been infrequently offered in mental health settings.  Tobacco free policies were slow to develop in psychiatric facilities.  Attitudes have changed among clinicians, but some harmful myths persist: "smoking is their one joy; it's treating their symptoms; they'll become psychiatrically unstable if they quit; it's hopeless to try; none of my patients want to quit; it's not my job to address it."

The strategy of AD: 1:1 clinician-facing outreach.

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. 

---

Click to see complete detail aid.

A key ingredient to our success has been our detail aid.  A great psychiatry resident (now attending), Kathryn Zioto, worked with Gail and me and the NaRCAD team to develop a detail aid about tobacco treatment in people with serious mental illness. 

The detail aid contains cutting-edge, evidence-based information in clear language with colorful graphics. It includes information about the MMHC’S Smoke Free Team, and highlights our three “asks”, which helps clinicians frame their conversations with patients:
​

• Ask about tobacco use
• Engage smokers in a discussion
• Act by referring patients to the Smoke Free Team 

---

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! 

Many good ideas have come from these meetings, and we have adapted the Smoke Free Team to respond to concerns and suggestions.  We've seen increases in referrals to the Smoke Free Team, and some prescribers are more actively engaged in the referral and treatment collaboration process, including the prescribing of smoking cessation medications. Time, as a resource, remains our biggest challenge.

​"It's been rewarding... prescribers are more actively engaged in the referral and treatment collaboration process."

NaRCAD AD Trainings: hands-on and interactive.

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.

---

NaRCAD: We’re excited that you’ll be sharing your data and results at this fall’s 4th International Conference on Academic Detailing here in Boston on November 14th & 15th. What do you want the clinical education community to know about your program or about AD in general?

Mark:  I think AD provides a robust, evidence-based template for achieving a variety of goals in healthcare.  It’s a process that can foster transformative change in healthcare systems and should be part of an organizational approach to change management in healthcare organizations.

​"AD [...] can foster transformative change in healthcare systems & should be part of an organizational approach to change."

Provider education, engagement and activation are key, and AD provides a framework that has a proven track record in producing results in these areas.  Plus, AD is efficient and easily implemented relative to other interventions--especially when you have assistance from NaRCAD!

​NaRCAD: Thanks for taking the time to connect with us. We’ve enjoyed helping to support this initiative with training and materials development! We look forward to continuing to learn about the impact you have on improving the health of people with serious mental illness, and sharing it with the community. We can't wait to hear more about this intervention at our conference this fall!

---

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. 

---