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Wisconsin Nicotine Treatment Integration Project (WiNTiP): Triggering a Paradigm Shift in Treating Patients with Mental Health and Addictive Disorders

July 28, 2011: Cessation: Emerging Interventions and Innovations

Eric Heiligenstein, M.D., University of Wisconsin

Dr. Heiligenstein provided an overview of the Wisconsin Nicotine Treatment Integration Project (WiNTiP) that works to integrate evidence-based nicotine dependence treatment into mental health, alcohol and other drug abuse (AODA) services. The rationale behind this effort is based in the belief that people with mental health and addictive disorders have a right to receive at least the same level of nicotine treatment that is the norm for the general population. Mental health/AODA clients are motivated to quit but less likely to be offered evidence-based treatment so they tend to try to quit without treatment. Even when they are offered the use of evidence-based treatment this population is less likely to succeed in quitting. Due to an engrained culture of tobacco use in the mental health and AODA settings, identification and treatment of tobacco use is often neglected and providers are often resistant to providing support to patients in efforts to quit.

WiNTiP has approached the issue in three phases. First, to gather information, a survey was sent to each Single State Agency (SSA) for Substance Abuse Services. Mental health and AODA providers were also surveyed and asked about willingness to provide tobacco use treatment to clients if they were trained in the delivery of this treatment. Only 3 percent of those surveyed stated that they would not be willing to provide such treatment. Seventy-two percent stated that they would be willing to add nicotine dependence treatment knowledge and skills to their professional credentialing requirements. Another element of the information gathering was to survey mental health/AODA consumers. Fifty-eight percent of those surveyed were current smokers and 28 percent were former smokers, indicating that it is possible for this population to quit successfully. While many of those surveyed wanted to quit, many were not sure they would be able to do so successfully and furthermore, many of these smokers didn't think that their providers had confidence in their ability to quit.

The second phase of WiNTiP's efforts was to build awareness of the importance of providing tobacco dependence treatment to the mental health/AODA population. Webinars were held, a website was created and electronic newsletters have been regularly distributed. In addition, many presentations have been conducted for providers during professional association meetings.

The third and final phase—currently underway—is training substance abuse and mental health professionals in the delivery of evidence-based tobacco dependence treatment. Much progress has been achieved in the number of patients who have been advised to quit and who receive referrals to the quitline.

Dr. Heiligenstein concluded with three lessons learned: mental health and AODA consumers do want to quit; mental health and AODA providers want to be trained, and the tobacco culture can be changed.

Following the morning panel, Dr. Fiore invited questions from Committee members.

Surgeon General Benjamin inquired about why the Massachusetts Mass Health program required prior authorization for pharmacotherapy. Ms. Warner clarified that prior authorization was only required for Zyban due to it being a brand name product. No prior authorization is required for other medications such as the patch or nicotine gum. A follow-up question was asked about cost savings realized from the Mass Health program. Dr. Land responded that gains in productivity are in line with other models. In response to an additional question about cost, Dr. Land responded that the cost of the program is approximately $170 per person for smokers using the benefit.

Panelists were asked to comment on what they viewed as an appropriate role for primary care physicians in assisting patients who smoke. Responses included the importance of training physicians to deliver evidence-based tobacco dependence treatment and that smokers need to be assisted with evidence-based treatment at whatever place they "touch" the healthcare system.

Dr. Heiligenstein was asked to comment on the reality that many substance abuse professionals are themselves smokers and whether that affects their ability to assist smokers in quitting. Dr. Heiligenstein confirmed that between 40-50 percent of substance abuse counselors are smokers and it is therefore important to push for social norm change that results from policy interventions such as smoke-free environments.

Dr. Husten asked for panelists to comment on the resounding theme of the morning presentations relating to barriers in access to evidence-based tobacco dependence treatment and whether there were suggestions for macro-level changes to address this problem. Responses included the need to take into account other risk factors when working with smokers who have mental health issues, the success of using community health workers to facilitate treatment, the challenge that the use of cell phones can create, and the importance of creating consumer demand for cessation services. Dr. McAfee responded to Dr. Husten's comment on macro-level change by asking whether there might be an important future role for lay health workers such as those involved in the Head Start pilot program described by Dr. Levinson. Dr. Levinson responded by saying that in this approach lay health workers do not provide the actual treatment, but instead serve to provide support and encouragement.

Dr. Wewers was asked about the Ohio Appalachian smokers study and whether it included assistance for the males in the household. Although this particular study did not, a second study targeting both women and men is underway. Because men do not access health care through public health clinics as frequently as women, it can be a challenge to reach male smokers. A follow-up question was asked about addressing the prison population and Dr. Wewers acknowledged that while many states have smoke-free restrictions in prisons, very few offer tobacco dependence treatment.

A question was asked of Dr. Heiligenstein regarding the use of incentives to encourage providers to get trained in tobacco dependence treatment and whether the program could have been successful without such incentives. Dr. Heiligenstein responded that he did not have the answer to this question but that WiNTiP's incentive was $99 a day which is fairly modest and probably not enough of an incentive to completely influence participation.

A final question was asked of Dr. Fiore related to Medicaid coverage for tobacco dependence treatment and whether the Exit Notification/Disclaimer Policy website could be a vehicle to help participants understand their eligibility for treatment. Dr. Fiore responded that Medicaid varies by state and there is a lot of variation in coverage among states.

Following questions, the meeting adjourned for lunch and the Committee reconvened at 1:05 pm.

Surgeon General Benjamin introduced the moderator of the first afternoon panel.

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