Acad Psychiatry 31:402-405, September-October 2007
doi: 10.1176/appi.ap.31.5.402
© 2007 Academic Psychiatry
Smoking Cessation Delivered by Medical Students Is Helpful to Homeless Population
Andrew Spector, M.D.,
Hilary Alpert, M.D. and
Maher Karam-Hage, M.D.
Received August 28, 2006; revised January 16, 2007; accepted February 15, 2007. All authors were affiliated with the University of Michigan Medical School, Ann Arbor, Michigan, at the time this article was written. Address correspondence to Dr. Spector, 4500 Pablo Road, Jacksonville, FL 32224; aspector{at}umich.edu (e-mail).
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ABSTRACT
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OBJECTIVE: The authors pilot a smoking-cessation outreach for the homeless that extends medical students’ tobacco cessation education. METHOD: In this prospective study, second-year medical students administered cognitive behavior therapy or unstructured support to homeless subjects to help them quit smoking. Self-report and biological measures (carbon monoxide) of smoking taken at baseline and follow-up were analyzed using t tests to determine intervention efficacy. RESULTS: Out of 11 enrolled subjects, six completed the protocol and all decreased their smoking frequency. The mean rate of smoking dropped significantly from 19 to nine cigarettes per day when pooling all subjects, and carbon monoxide mean level decreased from 28.0 to 20.2. CONCLUSIONS: The homeless subjects who received counseling from medical students significantly reduced their smoking frequency. Subject recruitment and retention were challenges, but a close partnership with local homeless shelters and the addition of pharmacotherapy could improve outcomes and are recommended for future efforts.
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INTRODUCTION
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Smoking affects some populations more than others: as many as 75% of homeless people smoke, compared to 57% in a matched nonhomeless cohort (1). Homeless people begin smoking at younger ages, smoke more frequently, and are less likely to contemplate quitting (2). They are more likely to practice high-risk smoking behaviors (e.g., smoking discarded cigarettes, tampering with filters). This makes homeless smokers more susceptible to tobacco-related health complications and infectious diseases (3).
Lack of health care resources poses a significant obstacle in delivering smoking cessation to the homeless. Medical student volunteers constitute a potential source for conducting smoking cessation counseling; partnering with homeless shelters could provide outreach to the homeless community. This, in turn, would help medical schools fulfill their mandate to improve tobacco education and to make competence in smoking cessation a graduation requirement (4). Currently, only 31% of U.S. medical schools (4) and 29% of clinical clerkships require such training (5). Our literature review identified one medical school with a student clinic for smoking cessation. Here, we extend this concept to reach the homeless, a medically underserved population that could benefit from volunteering medical students (6).
In this pilot study, we proposed, initially, to study 1) feasibility, 2) obstacles, 3) effect, and 4) differences between the therapy formats of medical students’ smoking cessation efforts with a homeless population. The therapies chosen were cognitive behavior therapy (CBT) and unstructured support. Pharmacotherapy was not used, as it would require close physician oversight, which would have diminished the independence of the medical students, and because pharmacotherapy would most likely be difficult for this economically disadvantaged population to acquire after the study period. If successful, this outreach model could provide a valuable service and correct a current deficit in medical school curricula.
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Method
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Subjects were regular smokers over the age of 18 and were recruited between January 2004 to October 2005 by case managers and a nurse practitioner from a local county homeless shelter. Exclusion criteria included age and the presence of a psychotic disorder, as identified by the nurse practitioner from the psychiatric history. Subjects with psychotic disorders were excluded because it was felt that second-year medical students were unprepared to independently counsel these patients. Second, exclusion avoided theoretical confounders, such as a subject’s ability to respond to CBT. The Institutional Review Board approved the study and all subjects gave written informed consent.
An addiction psychiatrist (M.K-H.) supervised the initial volunteer student-counselor’s training (A.S.) that consisted of observing experienced therapists for five sessions of individual and group therapy for substance abuse-dependence treatment, followed by 3 hours of reviewing the CBT program from the National Institute on Drug Abuse–Clinical Trials Network (NIDA-CTN). Three subsequent counselors were trained by their predecessors and the same addiction psychiatry faculty supervisor. All counselors were second-year medical students at the University of Michigan Medical School.
Subjects were randomly assigned to receive either CBT or unstructured support. The subjects were blinded to the type of therapy but the student-counselors were not. The experimental therapy program (CBT) was adapted for individual therapy from a group therapy protocol for smoking cessation (7). The nine CBT individual sessions included the same steps and principles as the original group therapy, consisting of 1) Introduction, 2) Preparing to Quit, 3) Quitting, 4) Staying off Cigarettes, 5) Relapse Prevention, 6) Healthy Management of Reality, 7) Thoughts and Mood, 8) People and Mood, and 9) Preventative Lifestyle. The unstructured support consisted of being emphatic and supportive while talking about smoking in general and inquiring about subjects’ reasons for quitting, without providing specific education, guidance, or encouragement to quit. All subjects received nine 20-minute sessions over the course of approximately 3 weeks. Students followed the NIDA-CTN protocol closely and maintained contact with the attending psychiatrist. Most subjects were appreciative of what the students were doing. Two potential subjects were skeptical about the ability of a "never-smoker" to provide smoking cessation counseling, and two other potential subjects were afraid of signing anything, including the informed consent; none of these subjects participated in the program.
At the first session, all subjects reported their current and past smoking experiences on a questionnaire designed for this study that included the Fagerstrom Test of Nicotine Dependence (FTND) (8) and their history of quit attempts. Within 1 week of completing the program, subjects retook the survey about their recent/current smoking behavior. At each therapy session, subjects underwent a breathalyzer to determine carbon monoxide levels as an objective measurement of recent smoking (9). The study outcomes (smoking reduction or cessation) were designed to be within-subject repeated measure analyses to determine the efficacy over time and across interventions (CBT versus unstructured support). Because of small numbers per treatment group, we were unable to compare CBT versus unstructured support formats; our final analysis examined pre- and postdifferences (including the number of cigarettes and amount of carbon monoxide [CO]) using a pooled analysis with all six completers.
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Results
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Of the 11 consenting subjects, the mean age was 40.6 (SD=10.8) years. Two were women. Subjects reported smoking regularly for 23.2 (SD=11.7) years with 5.4 (SD=3.8) prior quit attempts. The mean FTND prior to the intervention was 6.1 ("high dependence"). Subjects reported an average desire to quit of 7.3 out of 10 (range=1 to 10).
Of the initial 11 subjects, six completed the nine-session protocol; three received CBT. All but one completed the follow-up survey. Subjects reported a significant decrease in smoking: their average use of cigarettes dropped from 19.0 to 9.0 per day (p=0.008). Carbon monoxide data showed a significant decrease in the mean level from baseline for sessions 5 through 7, from 28.0 (SE=5.2) to 20.2 (SE=3.5), with p=0.02; then CO level reached a plateau for sessions 8 and 9 (Figure 1).
None of the five subjects who failed to complete the nine sessions provided reasons for discontinuing. All moved from the homeless shelter without providing contact information. The modal number of therapy sessions attended by those who did not complete all nine was 1 (range=1 to 2 sessions).
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Discussion
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In an underserved population that is markedly difficult to reach and engage, we present a proof of concept for our primary aim: medical students providing meaningful smoking cessation, with the smoking rate decreasing significantly during a 3-week intervention in this group of homeless people. We observed this outcome without providing pharmacology or incentives for patients to quit smoking; however, subjects’ motivation to quit was relatively high (mean of 7.3 on a scale of 0 to 10). All four medical students who participated (including A.S. and H.A.) reported appreciating the opportunity to help the disadvantaged population; they liked the relative independence and the experience of counseling others and felt they had more tools to engage smokers in the future. These statements constitute an encouraging outcome for this pilot project.
Some procedural lessons we learned: 1) the nurse practitioner and case managers were eager for the subjects to quit smoking and actively helped in the process of recruiting; in contrast, no subjects called the hot line on the recruitment posters, as we had initially expected; 2) some potential subjects did not join because they were suspicious of signing a lengthy informed consent document; 3) others declined to participate in any smoking cessation program run by counselors who themselves had never smoked. We speculate that involving shelters’ personnel may further attenuate these difficulties. Shelter staff are more familiar to subjects than the student-counselors and therefore could serve as trusted advisers, reassuring subjects about the safety and potential benefits of such programs.
This study did not include pharmacotherapy of any kind, which kept costs low and enabled medical students’ independence. Future medical school studies or programs may choose to provide nicotine replacement therapy, which might improve the number of willing subjects and their retention and success rates. Furthermore, with pharmacotherapy use and faculty oversight, it may be unnecessary to exclude those with stable psychotic disorders, as drugs such as bupropion have been found effective and safe for smoking cessation in this group (10). Therefore, including pharmacotherapy (over-the-counter or prescription) in a future homeless smoking cessation outreach may enhance participation and outcomes.
Subject retention is a major concern. This study required subjects to meet a therapist on nine occasions. Unfortunately, once a subject misses a meeting, he or she becomes very difficult to locate. A shorter interval between appointments and including tokens of reinforcement (e.g., free nicotine replacement therapy) might encourage subjects to continue the program without creating financial demands.
Although the low subject numbers did not provide enough power to identify potential differences between the therapies, there was a significant decrease in the mean number of smoked cigarettes per day when results were pooled among those who completed all nine sessions, including one subject who approached abstinence (one cigarette per day). The CO data provided biological corroboration of decreased smoking during sessions 5 through 7 compared to session 1 (baseline). So, even without pharmacotherapy evidence of behavioral change emerged. For medical students, receiving training in CBT and behavioral modification strategies could be extremely useful in counseling patients with a variety of conditions. Although this small sample did not provide any conclusions about CBT versus unstructured support, a medical school seeking to train students in CBT could choose smoking cessation as its launching point.
This type of outreach provides students with valuable experiences with tobacco cessation strategies (6) and caring for the homeless. The homeless could benefit from a forum for helping them quit smoking, a service that could have widespread public health benefits. Finally, both medical students and the homeless would benefit from reinforcing the idea that smoking behavior is amenable to change.
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ACKNOWLEDGMENTS
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Blue Cross Blue Shield of Michigan Foundation Student Award Program and the David E. Rogers Fellowship of the New York Academy of Medicine provided financial support to Dr. Spector.
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REFERENCES
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- Szerlip MI, Szerlip HM: Identification of cardiovascular risk factors in homeless adults. Am J Med Sci 2002; 324:243–246[CrossRef][Medline]
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- Fiore MC, Croyle RT, Curry SJ, et al: Preventing 3 million premature deaths and helping 5 million smokers quit: a national action plan for tobacco cessation. Am J Public Health 2004; 94:205–210[Abstract/Free Full Text]
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- Muñoz RF, Organista K, Hall S: Mood Management Training to Prevent Smoking Relapse: A Cognitive Behvioral Treatment Manual. San Francisco, University of California, 1988
- Heatherton TF, Kozlowski LT, Frecker RC, et al: The Fagerstrom Test for Nictoine Dependence: a revision of the Fagerstrom Tolerance Questionnaire. Br J Addict 1991; 86:1119–1127[CrossRef][Medline]
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- George TP, Vessichhio JC, Termine A, et al: A placebo-controlled trial of bupropion for smoking cessation in schizophrenia. Biol Psychiatry 2002; 52:53–61[CrossRef][Medline]
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ABSTRACT
INTRODUCTION
