Clinical Psychologists and Smoking Cessation: Treatment Practices and Perceptions

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J Community Health (2009) 34:461–471
DOI 10.1007/s10900-009-9178-0
ORIGINAL PAPER
Clinical Psychologists and Smoking Cessation:
Treatment Practices and Perceptions
Sutoidem M. Akpanudo Æ James H. Price Æ
Timothy Jordan Æ Sadik Khuder Æ Joy A. Price
Published online: 22 August 2009
Ó Springer Science+Business Media, LLC 2009
Abstract A random sample of clinical psychologists was
surveyed regarding their smoking cessation practices and
perceptions. A total of 352 psychologists responded (57%)
to the valid and reliable questionnaire. The majority
(59.1%) of psychologists did not always identify and
document the smoking status of patients. The majority
reported high efficacy expectations (66.4%) and low outcome expectations (55.1%) for using the 5A’s smoking
cessation counseling technique. Counselors that had never
smoked were almost two times more likely to have higher
efficacy expectations than those that were current smokers
or ex-smokers (OR = 1.94, 95% CI 1.18–3.12). The factors that predicted regular use of the 5A’s included the
number of identified barriers, psychologists’ level of self
efficacy, and the urbanicity of one’s practice location.
Keywords Smoking cessation Clinical psychologists 5A’s Nicotine replacement therapy (NRT)
Introduction
Tobacco use is the single most preventable cause of morbidity and mortality in the United States [1]. Approximately 440,000 people die of a tobacco related illness in
the United States each year resulting in significant healthrelated and economic costs to the country [2]. Despite an
increasing prevalence of clean air laws and social norms
against smoking, 45.8 million adults in the United States
continue to smoke [3, 4].
The vast majority of adult smokers (70%) desire to stop
smoking and 40% of them will make a serious attempt to
quit each year [5, 6]. Behavioral support in the form of
brief counseling interventions has been shown to help
tobacco users stop smoking [7], especially those users that
have regular and in depth contact with health care
professionals.
Smoking and Mental Health
S. M. Akpanudo T. Jordan
Department of Health & Rehabilitative Services, College of
Health Science and Human Service, The University of Toledo,
2801 W. Bancroft St., Mail Stop # 119, Toledo, OH 43606, USA
J. H. Price (&) S. Khuder
Department of Public Health, College of Medicine @ Health
Science Campus, The University of Toledo, 3120 Glendale
Avenue, Mail Stop #119, Toledo, OH 43614, USA
e-mail: [email protected]
J. A. Price
Zepf Community Mental Health Center, 6605 W. Central
Avenue, Toledo, OH 43617, USA
Active psychiatric disorders, including major depression,
anxiety disorders and substance use disorders, significantly
predict the onset of daily smoking and progression to
nicotine dependence [8]. The incidence of smoking among
individuals suffering from various forms of mental illness
is inordinately high; approximately 60% overall, compared
to 25% in the general population [9]. Furthermore, 30% of
all smokers in the United States have some form of mental
illness. These mentally ill smokers purchase the majority of
cigarettes sold [9].
Nicotine dependent individuals make up 12.8% of the
national population yet consume 57.5% of all cigarettes
smoked in the US [10]. Nicotine dependent individuals
with co-morbid mental health disorders make up 7.1% of
the national population yet consume 34.7% of all
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cigarettes. Further, nicotine dependent individuals and
psychiatrically ill individuals consume approximately 70%
of all cigarettes smoked nationally [10]. Compounding this
problem is the fact that mental health patients, especially
those with depression, schizophrenia, and alcohol problems, also face special challenges in quitting tobacco use
[11–14].
Practice Guidelines for Smoking Cessation
In 2000, a set of guidelines to promote smoking cessation
in the clinical setting was established by an expert panel
consisting of representatives from various government and
non-profit agencies (National Cancer Institute, CDC’s
Office on Smoking and Health, US Agency for Healthcare
Research and Quality, National Heart, Lung, and Blood
Institute, National Institute on Drug Abuse, Robert Wood
Johnson Foundation, and the Center for Tobacco Research
and Intervention at the Wisconsin Medical School). The
recommendations for clinicians set forth by this panel
included two brief counseling interventions: the 5R’s and
the 5A’s [7].
The 5R’s counseling technique is recommended for
patients that smoke who are not yet willing to make a quit
attempt. The primary objective of the 5R’s is to increase
patients’ motivation to quit. The 5R’s include Relevance
(encourage the patient to indicate why quitting smoking is
personally relevant for him and his significant others; Risks
(ask the patient to identify potentially negative consequences of tobacco use, particularly those that seem most
relevant to the patient); Rewards (ask the patient to identify
potential benefits of quitting); Roadblocks (ask the patient
to identify barriers to quitting and point out elements of
treatment that could overcome those barriers); Repetition
(this motivational intervention should be repeated every
time an unmotivated smoker visits the clinical setting) [7].
In contrast, the 5A’s counseling technique is to be used
with patients that are motivated to make a quit attempt. The
5A’s include Ask (ask about tobacco use at each visit),
Advise (strongly advise all tobacco users in the household
to quit), Assess (assess willingness to make a quit attempt;
if unwilling, provide motivation to quit), Assist (assist the
parent in quitting through counseling about quitting
smoking, giving reading materials, etc.), Arrange (arrange
personal or telephone follow-up visits to encourage
cessation).
Smoking Cessation and Clinical Psychologists
Compared to other health care professionals, clinical psychologists benefit from a number of potential advantages in
offering smoking cessation counseling and treatment.
Psychologists are specifically trained in motivational
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techniques and have special expertise in helping patients
change their behavior [15]. Research has also demonstrated
that clinical psychologists are more effective and more
trusted by patients than other healthcare providers in conducting smoking cessation counseling [16, 17]. In addition,
clinical psychologists have more personal contact time
with patients than do other health care providers. Furthermore, a substantial proportion of a psychologist’s patients
are likely to be tobacco users [15, 18].
Four studies could be found in the literature that assessed clinical psychologists and their smoking cessation
activities. Only one of those studies was a national study of
American psychologists and it was limited by a 26% return
rate.
A survey of 256 psychologist members of the APA
(26% return rate), reported that none of the 5A’s steps were
consistently practiced by the majority of respondents [15].
Only 29% of psychologists asked all patients about their
smoking status while 31% advised all smokers to quit.
Moreover, psychologists were less likely to advise smokers
to quit smoking or to assess patients’ willingness to quit
than they were to advise patients and assess their readiness
to change other risky health behaviors such as unsafe sex,
reckless driving, and gambling.
In Massachusetts a study of 154 psychologists (31%
return rate) found that 43% asked new clients about their
smoking status [19]. One in three psychologists reported
advising their smoking patients to quit while only 12%
assisted their patients with quitting and arranged resources
to help the patient.
A Swedish study of 846 psychologists (85% return rate)
reported that only 8% of psychologists frequently asked
their patients about tobacco use; 9% gave advice to
smoking patients to quit; and only 1% actually gave cessation support [20]. A majority of Swedish psychologists
(75%) believed that it was not their responsibility to help
patients stop smoking while nearly the same proportion
believed that they lacked the skills to help smokers quit.
A study of 143 psychologists in Oklahoma (35%
response rate) found that 35% of their respondents asked
every patient about tobacco use; 50% reported assessing
smokers readiness to make a quit attempt; 76% reported
advising smokers to quit at least occasionally; and 90%
reported assisting patients in making a quit attempt [21]. It
should be noted that a minority of psychologists (27%)
asked their smoking patients if smoking cessation could be
included in the treatment plan and goals while only 30%
‘‘always’’ or ‘‘often’’ included tobacco use cessation as a
part of the treatment plan.
The primary goal of the current study was to answer the
following questions: Where do clinical psychologists place
themselves in the Stages of Change Model with regard to
smoking cessation counseling? Do clinical psychologists
J Community Health (2009) 34:461–471
regularly employ the 5A’s counseling method with their
patients that smoke? Do clinical psychologists regularly
employ the 5R’s counseling method with smokers that are
not ready to quit? What are clinical psychologists’ perceived barriers and perceived benefits to smoking cessation
counseling? What are clinical psychologists’ efficacy
expectations, outcome expectations and outcome values
regarding the 5A’s smoking cessation counseling technique? From what sources do clinical psychologists obtain
the majority of their education regarding smoking
cessation?
Method
Participants
A nation-wide, simple random sample of clinical psychologists was selected from the 2005 directory of the
National Register of Health Service Providers in Psychology. An a priori power analysis was calculated by setting
alpha at 0.05, the effect size at 0.20, and power at 0.90 (two
tailed test). The power analysis revealed that a sample size
of 315 completed surveys was needed to generalize the
findings to the entire population based on a 5% sampling
error and a 70/30 split in smoking cessation counseling
behaviors of psychologists, as reported in previous studies
[15, 22]. Thus, to ensure an adequate response rate, 650
surveys were mailed to potential respondents [15, 19].
Measures
The survey instrument was a four-page, 31-item, closed
format style instrument. The Stages of Change Theory
(precontemplation, contemplation, preparation, action and
maintenance stages) was used to assess respondents’ stage
of smoking cessation counseling implementation [23].
Additional items were constructed to measure how frequently psychologists used the USPHS (United States
Public Health Service) guidelines for smoking cessation
counseling for patients that were willing to quit (5A’s) and
for patients that were unwilling to quit (5R’s) [7].
The amount of time spent on counseling indicates
intensity of the intervention. The USPHS guidelines for
smoking cessation counseling categories were divided into
three categories: minimal intensity (3 min or less), low
intensity (3–10 min), and high intensity counseling
(10 min or longer) [7]. One item on the survey examined
how much time clinical psychologists spent counseling
each smoker.
The Health Belief Model [24] was used to construct
items which examined the two most important components: perceived benefits and barriers of psychologists who
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did and did not apply the USPHS recommendations. The
Self-Efficacy Theory was used to construct items to assess
psychologists’ efficacy expectations, outcome expectations
and outcome value expectations concerning smoking cessation counseling [25]. Efficacy expectations are one’s
personal convictions or beliefs that he/she can successfully
perform the behavior(s) required to produce specific outcomes, in this case smoking cessation. Outcome expectations are one’s beliefs about whether a particular behavior
will lead to particular consequences or outcomes. Outcome
values are the values the respondent attaches to the perceived outcomes of performing a specific behavior, in this
case the 5R’s and 5A’s counseling techniques [25].
Content validity of the survey instrument was established
by having it reviewed and critiqued by a panel of published
experts (n = 5) in survey research and behavioral models
used in this study. Principal component analysis was conducted, followed by factor analysis using Varimax rotation
to establish construct validity of the subscales (using 0.40 or
higher for item loadings on factors).
Stability reliability of the instrument was established by
administering the survey twice within a 10-day time period
to a small convenience sample (n = 10) of local clinical
psychologists that were not included in the study sample. The
overall stability reliability coefficient was 0.71. The stability
reliability coefficients for the subscales ranged from 0.51 for
efficacy expectations to 1.00 for the Stages of Change.
The internal reliability of the instrument subscales were
established using Cronbach alpha analysis of the responses
from the final sample. The subscales of the instrument had
internal consistency coefficients ranging from 0.78 for the
5R’s subscale to 0.88 for the outcome expectations
subscale.
Procedure
Following approval of the study proposal by the University
Human Subjects Research Review Committee in the fall of
2005, each potential respondent was mailed a personalized
hand-signed cover letter describing the purpose of the
study, a copy of the survey on blue colored paper, a selfaddressed stamped envelope and a one dollar bill as a token
of appreciation (incentive). These techniques have been
shown to increase response rates [26–28]. A second mailing was sent to all participants who did not respond within
2 weeks. Finally, a postcard was sent as a reminder to all
participants who did not respond within 4 weeks [27, 28].
Data Analysis
Data analysis was performed using SPSS 14.0 for windows
statistics software package. An a priori alpha level was set
at P \ 0.05 to reduce the chances of a type I error. The
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appropriate descriptive statistics and inferential statistics
were used to describe the findings.
Table 1 continued
Item
Responses
Number
Results
Average client load per week
Characteristics of Respondents
Of the 352 completed surveys (57%) returned, the vast
majority, 157 (72.2%) were male (Table 1). An over
whelming majority of the clinical psychologists were White
(95.3%). A little less than one-half of the clinical psychologists (46.2%) were between the ages of 50 and 59 years.
%
Sex
Male
Female
242
93
59
17.7
10–19
80
24.0
20–29
71
21.3
30–39
72
21.6
40–49
34
10.2
50 and above
18
5.4
172
169
49.3
48.4
8
2.3
City
162
46.7
Suburban
Smoking status
Ex-smoker
Never smoked
Area of practice
Responses
Number
0–9
Current smoker
Table 1 Demographic characteristics of the respondents
Item
%
72.2
27.8
Age
133
38.3
Rural
40
11.5
Inner city
12
3.5
Northeast
105
30.5
South
Geographic region of practice
40–49
5
1.5
102
29.7
50–59
159
46.2
Midwest
75
21.8
60–69
143
41.6
West
62
18.0
37
10.8
N ranges from 340 to 352
Approximately one-half (49.3%) were ex-smokers while
2.3% were current smokers.
70 and older
Race/ethnicity
Caucasian/non-hispanic white
327
95.3
Hispanic/Latino
6
1.7
Asian/Pacific islander
5
1.5
Native American
3
0.9
African American/non-hispanic black
2
0.6
223
65.2
119
34.8
Private
280
80.9
Other
32
9.2
Academia
14
4.0
Community mental health center
13
3.8
7
2.0
331
94.8
18
5.2
11
3.2
Employment status
Full-time
Part-time
Primary type of practice
Veterans affairs medical center
Age group of patients
Adults
Adolescents
Years of full time practice
0–9
10–19
16
4.7
20–29
30–39
143
144
41.6
41.9
40–49
26
7.6
4
1.2
50 and above
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Stages of Change Status
The majority of the clinical psychologists (52.6%) reported
they were in the ‘‘maintenance stage’’ for smoking cessation counseling (i.e., had been giving smoking cessation
advice to their patients for longer than 6 months), while
about a third (32.3%) were in the ‘‘pre-contemplation
stage’’ (had not thought about offering smoking cessation
counseling to their patients). Almost one-tenth (9.3%)
reported they were in the contemplation stage (i.e., thinking about starting to give smoking cessation advice).
Identification and Documentation of Patients
Who Smoke
Slightly more than 40% (40.9%) of the clinical psychologists reported that they always (100% of the time) identified and documented their patients smoking status, while a
little more than a quarter (26.8%) reported that they usually
(about 75% of the time) identified and documented
smoking status. Only 3% reported they never documented
their patients’ smoking status. A series of chi-square tests
J Community Health (2009) 34:461–471
revealed no statistically significant relationship between
psychologists’ behavior in identifying and documenting
client’s smoking status and primary type of practice,
number of patients seen per week, psychologists smoking
status, or their practice setting.
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Table 2 Factors associated with time spent on smoking cessation
counseling
Variable (score range)
Minutes
N
Mean
SD
128
5.43
3.73
52
6.31
3.42
34
3.47
2.97
130
6.28
3.49
Low (6–18)
83
4.42
3.45
High (19–30)
86
6.57
3.35
Gender
Use of 5A’s in Tobacco Cessation Counseling
About one-quarter (24.5%) of respondents always gave a
clear, strong, and personalized message to their patients
that smoked, urging them to quit. Only one in ten psychologists reported that they always assessed whether the
patient that smoked was willing to make a quit attempt in
the near future. A little less than one-third (30.4%) of the
clinical psychologists indicated that for smokers that are
willing to make a quit smoking attempt, they or their staff
always provided counseling. About one-fifth (19.3%)
indicated that they always assisted patients who smoked by
encouraging the use of problem solving skills for smoking
cessation. Furthermore approximately one-fifth (19.1%)
always scheduled follow-up contacts, in person or by
telephone, within the first week after the quit date, for the
patients who established a quit date.
When it came to recommending nicotine replacement
therapy (NRT), 5% of respondents reported they always
recommended NRT to assist patients who wanted to quit.
Surprisingly, only 5.5% of psychologists provided self-help
smoking cessation materials to patients that smoked. Just
under 14% of respondents reported that they always
assisted patients who smoked by providing and/or arranging for social support to help them quit.
Use of 5R’s for Patients Unwilling to Quit Smoking
Only about one-fifth (18.9%) of clinical psychologists
always explained to patients who smoked why quitting was
personally relevant. About one-quarter always explained to
patients the risks of continued smoking (25.4%); explained
the potential benefits of quitting smoking (28.1%); asked
patients to identify their barriers to quitting (24.0%); and
attempted to motivate patients to quit (24.2%). For patients
unwilling to quit smoking, about one-tenth (11.4%) of the
clinical psychologists did not further address patients’
smoking behavior. Other actions taken by clinical psychologists included getting a concerned other to assist with
quitting, getting permission to consult/confer with client’s
primary care physician, including smoking cessation
counseling with stress management, and offering hypnosis.
Time Spent on Smoking Cessation Counseling
A little less than one-half (45.1%) of the clinical psychologists spent between 3 and 10 min counseling their
Male
Female
Efficacy expectations*
Low (6–18)
High (19–30)
Outcome expectations*
N ranges from 164 to 180 because this only applies to respondents
who identified and counseled their smoking patients on smoking
cessation
Time is number of minutes spent counseling on smoking cessation
* Significant at the P \ 0.05 level (t-test)
smoking patients on smoking cessation (low intensity); a
little more than one-third spent (37.6%) ten or more minutes
(high intensity); while less than one-fifth (17.3%) spent
three or less minutes. T-tests indicated statistically significant relationship between the amount of time psychologists
spent on smoking cessation counseling and their levels of
efficacy expectations and outcome expectations (Table 2).
Those with higher efficacy expectations spent 82% more
time counseling patients regarding smoking cessation while
those with higher outcome expectations spent 49% more
time counseling patients than those with lower efficacy
expectations or lower outcome expectations, respectively.
Perceived Barriers and Benefits to Smoking Cessation
Counseling
Respondents were asked to select from a list of potential
barriers that may make it difficult or challenging to provide
smoking cessation counseling to patients that smoke. The
most frequently selected barrier was ‘‘not the client’s presenting problem’’ (57.1%). About one-fourth (28.7%)
selected ‘‘I do not see this as a priority for my patients.’’
Approximately one-fifth of the clinical psychologists
selected ‘‘may interfere with therapy goals’’ (21.2%) and
‘‘smoking patients are not interested in smoking cessation
counseling’’ (19.8%). ‘‘My lack of training in tobacco
cessation skills’’ was selected by 17.1% of the clinical
psychologists.
In terms of the perceived benefits of offering smoking
cessation counseling to patients, the majority (83.3%) of
clinical psychologists selected ‘‘enhances overall client
health.’’ About one-half selected ‘‘makes the client feel
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Table 3 Factors associated with number of perceived barriers to smoking cessation counseling
Variable (score range)
Number of perceived barriers
Number of perceived benefits
SD
N
Meanb
SD
1.94
1.60
148
2.85
1.69
1.74
1.74
65
2.77
1.63
N
Mean
236
93
a
Gender
Male
Female
Efficacy expectations*
Low (6–18)
High (19–30)
Outcome expectations*
Low (6–18)
High (19–30)
97
2.77
1.41
46
2.43
1.47
190
1.42
1.53
146
2.99
1.68
159
2.47
1.69
96
2.39
1.64
130
1.19
1.31
97
3.33
1.55
N ranges from 286 to 329
a
Potential range 0–12
b
Potential range 0–6
* Significant at the 0.05 level (t-test)
confident that I have his/her best interest in mind’’ (55.9%),
‘‘it is an effective means of helping patients to quit
smoking’’ (49.1%), and ‘‘it makes me feel satisfied that I
am providing the best care for my patients’’ (46.8%).
About one-third selected ‘‘smoking cessation helps reduce
client’s psychological symptoms,’’ while 16.5% of
respondents wrote in other various perceived benefits.
The number of identified perceived barriers and benefits
both differed in a statistically significant way by the psychologists’ level of efficacy expectations and outcome
expectations but not by gender (Table 3). T-test analysis
indicated that clinical psychologists with higher efficacy
expectations for smoking cessation counseling identified
statistically significantly fewer perceived barriers to providing smoking cessation counseling (t = 7.29, df = 285,
P \ 0.01). Likewise, those who had higher outcome
expectations for smoking cessation counseling identified
statistically significantly fewer perceived barriers to providing smoking cessation counseling (t = 7.06, df = 287,
P \ 0.01).
Outcome Expectations and Use of the 5A’s
More than one-half (55.1%) of the clinical psychologists
believed that applying the 5A’s would not result in fewer
patients continuing to smoke (low outcome expectations).
There were no statistically significant associations between
use of the 5A’s counseling technique and clinical psychologist’s gender, smoking status, or type of practice.
Recommendation of Nicotine Replacement
Therapy (NRT)
The vast majority 95% of the clinical psychologists did not
always recommend nicotine replacement therapy for
smoking cessation. A series of chi-square or Fisher’s exact
tests showed that recommending NRT was not statistically
significantly associated with clinical psychologist’s gender,
level of efficacy expectations, or level of outcome
expectations.
Efficacy Expectations and Use of the 5A’s
Sources of Information Regarding Smoking Cessation
Counseling
The majority (66.4%) of the clinical psychologists were
confident (high efficacy expectations) in their ability to
effectively apply the 5A’s in smoking cessation counseling.
Clinical psychologists who had never smoked were almost
two times more likely to have a higher level of efficacy
expectations than were current smokers or ex-smokers
(OR = 1.94, 95% CI 1.18–3.12). There was no statistically
significant association between the use of the 5A’s counseling technique and the gender or type of clinical practice.
A little more than one-third (36.8%) of the clinical psychologists reported that they had not received any formal
information on smoking cessation. Almost one-half
(43.3%) reported they ‘‘read about the topic in professional
journals,’’ while about one-third (32.5%) reported they
obtained information from ‘‘professional conferences,
conventions, and/or meetings.’’ Approximately one-quarter
(26.9%) of respondents reported that their primary source
of information was ‘‘continuing education programs’’,
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while about one-fifth (21.1%) reported that they get most of
their information from ‘‘patients who smoke’’.
Factors Associated with Regular Application of 5A’s
Logistic regression modeling revealed that the number of
barriers identified, the level of efficacy expectations, the
level of outcome expectations, and the location of one’s
practice were statistically significant predictors of regular
use of the 5A’s. Increased number of identified barriers
statistically significantly reduced the likelihood of regular
use of the 5A’s by more than one-half (Wald = 13.6,
P \ 0.01; adjusted OR = 0.41; 95% CI 0.26–0.66). High
efficacy expectations statistically significantly increased
the likelihood of regular use of 5A’s by more than 28 times
(Wald = 8.26, P \ 0.01; adjusted OR = 28.31; 95% CI
2.90–276.91).
High outcome expectations statistically significantly
increased the likelihood of regular use of 5A’s by almost
six times (Wald = 4.89, P = 0.03; adjusted OR = 5.83;
95% CI 1.22–27.80). Concerning the location of one’s
practice, those that practiced in rural areas had an increased
likelihood of regular use of 5A’s as compared to the inner
city (referent group) (Wald = 4.77, P = 0.29; adjusted
OR = 132.46; 95% CI 1.65–10,611.86). The Hosmer and
Lemeshow goodness-of-fit test was not statistically significant, indicating that the model was a good fit for the
data.
High Efficacy and Outcome Expectations
Logistic regression modeling revealed that the number of
identified barriers, the level of outcome expectations, and
the respondent’s smoking status were statistically significant predictors of high efficacy expectations in smoking
cessation counseling. Increased number of identified barriers was statistically significantly associated with a
reduced likelihood of high efficacy expectations by almost
one-half (adjusted OR = 0.57; 95% CI 0.44–0.74). High
outcome expectations statistically significantly increased
the likelihood of high efficacy expectations by more than
six times (adjusted OR = 6.35; 95% CI 2.57–15.64).
Concerning smoking status, an ex-smokers’ likelihood of
having high efficacy expectations was two-thirds less than
those who had never smoked (adjusted OR = 0.29; 95%
CI 0.12–0.68). The Hosmer and Lemeshow goodness-of-fit
test was not statistically significant.
Logistic regression modeling showed that the number of
identified barriers and the level of efficacy expectations
were both statistically significant predictors of high outcome expectations in smoking cessation counseling. An
increased number of identified barriers statistically
significantly reduced the likelihood of high outcome
467
expectations by almost one-half (adjusted OR = 0.55; 95%
CI 0.43–0.71). High efficacy expectations statistically
significantly increased the likelihood of high outcome
expectations by more than five times (adjusted OR = 5.21;
95% CI 2.16–12.56). The Hosmer and Lemeshow goodness-of-fit test was not significant.
High Outcome Value of Smoking Cessation Counseling
Logistic regression modeling showed that the number of
barriers identified and the number of benefits identified
were both statistically significant predictors of high outcome value in smoking cessation counseling. An increased
number of identified barriers statistically significantly
reduced the likelihood of high outcome value by almost
four times (adjusted OR = 0.26; 95% CI = 0.10–0.70)
whereas an increased number of identified benefits statistically significantly increased the likelihood of high outcome value by almost six times (adjusted OR = 5.85; 95%
CI 1.92–17.78). The Hosmer and Lemeshow goodness-offit test was not significant.
Discussion
The current study found more than one-half (52.6%) of
clinical psychologists routinely asked their patients if they
smoked (maintenance stage), while one-third of the clinical
psychologists never asked and had never thought about
asking (pre-contemplation phase). Previous studies have
reported that a range of 8–43% of psychologists routinely
ask their patients about smoking status [15, 19–21]. The
fact that 33% of clinical psychologists in the current study
did not routinely ask all their patients about their smoking
status indicates that many patients are not given the
opportunity to be advised on how to quit smoking. This is
an especially significant omission considering that tobacco
use, more than any other health risk, is more likely to kill
people with mental health disorders. In addition, not giving
one’s patients the opportunity to be advised and assisted
with smoking cessation may cause the patient and his/her
family to miss the enormous health benefits associated with
smoking cessation. Consequently, continuing education
efforts for practicing clinical psychologists should be
aimed at helping those in the pre-contemplation and contemplation stages of providing smoking cessation counseling to move to the action stage.
The current study found that of the 53% of clinical
psychologists that asked their patients about smoking, less
than one-half (40.9%) always identified and documented
the smoking status of all their patients. This implies that
less than one-quarter (21.5%) of clinical psychologists
actually complied with the USPHS recommendations.
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These findings suggest that most clinical psychologists
are not actively keeping track of their patients’ smoking
behavior and may not be providing appropriate smoking cessation counseling. Documenting a patient’s smoking
status is the simple yet critical baseline starting point for
future smoking cessation counseling, monitoring, and follow-up. If a patient is not asked, it is unlikely that he/she
will be advised, assessed, or assisted with quitting
smoking.
Several studies have indicated that the appropriate
application of the 5A’s counseling method for smoking
cessation significantly increases quit rates [29–31]. The
current study found that a minority of clinical psychologists used the recommended means of helping patients to
quit smoking. Since 52.6% of clinical psychologists asked
about smoking status and 61.1% employed the 5A’s in
smoking cessation counseling, it means that in absolute
terms about one-third (32.1%) of clinical psychologists
applied the recommended 5A’s steps of smoking cessation.
Others have reported that only 13.3% of patients with
mental health disorders were offered smoking cessation
counseling [32]. These findings point to an urgent need to
develop a comprehensive and coordinated effort for
smoking cessation for mental health patients, which will
require clinical psychologists to adopt and routinely apply
the USPHS recommendations.
Effective smoking cessation will require a systematic,
comprehensive multichannel, multimodality team approach
in which all members of the health care team utilize recommended science-based cessation guidelines. Research
indicates that the greater the variety of health professionals
that intervene to help a patient stop smoking, the greater
the likelihood that the patient will attempt to quit [33].
Thus, clinical psychologists need to recognize that they
play an important and valuable role as a member of the
health care team.
It was interesting to note that clinical psychologists
practicing in the rural/suburban areas were significantly
more likely to apply the 5A’s than those practicing in the
inner city/urban setting. Similar findings have been reported for smoking cessation counseling by physicians in inner
city hospitals with large minority populations, in comparison to hospitals located in suburban settings with low
minority populations [34]. One reason for this disparity in
counseling behavior may be that clinical psychologists in
inner city/urban settings see more patients per week and
therefore spend less time with each patient. Another possibility is that clinical psychologists in the inner city/urban
setting see more low socioeconomic patients who are less
well educated. Such patients may be perceived as being
less interested in smoking cessation counseling. A significant demographic bias in physician smoking cessation
practices has been reported. Minority and female patients
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J Community Health (2009) 34:461–471
were less likely to be asked about their smoking status and
less likely to be offered smoking cessation counseling [35].
The vast majority of clinical psychologists in this study
did not apply the 5R’s for patients that smoked but who
were unwilling to quit. It may be that most clinical psychologists were not familiar with the 5R’s. Studies examining smoking cessation counseling by various health
professionals consistently report more frequent use of
components of the 5A’s as compared to components of the
5R’s [31, 36]. This increased attention to the 5A’s has
caused a greater emphasis on the 5A’s in educational
programs for health care professionals, relegating the 5R’s
component to relative obscurity.
In terms of where psychologists get their information
about smoking cessation, most reported using professional
journals as their primary information source. This finding
has been corroborated by others who reported that ‘‘reading
about the topic’’ was the primary method of training for
psychologists [15]. Unfortunately, few published journal
articles include the 5R’s when dealing with smoking cessation counseling. In addition, only 13% of clinical psychologists have reported receiving any training or
education on the current USPHS recommendations for
smoking cessation indicating a glaring need in clinical
psychologists’ educational training programs [15].
Research has demonstrated that smoking cessation
counseling lasting between 3 and 10 min (low intensity
counseling, sometimes referred to as brief intervention)
significantly increases smoking cessation rates [7, 37–41].
Past research also indicates that the greater the intensity of
smoking cessation counseling (i.e., the greater the amount
of time spent on counseling), the more likely it is to bring
about smoking cessation [7, 42]. In the current study, the
vast majority (82.7%) of the clinical psychologists reported
spending three or more minutes in smoking cessation
counseling. Studies of other health care providers found
similar results [42, 43]. This encouraging finding suggests
that when clinical psychologists do provide smoking cessation counseling, they are setting aside sufficient time to
advise smokers at a level of intensity that would maximize
the chances of smoking cessation.
It was interesting to note that clinical psychologists in
the current study with high efficacy and outcome expectations spent significantly more time on smoking cessation
counseling than those with low efficacy and outcome
expectations. Therefore, if efforts are focused on increasing
clinical psychologists’ efficacy expectations (e.g., smoking
cessation skills training during medical school and residency) and outcome expectations (e.g., education on the
effectiveness of the USPHS recommendations and NRT
use for smoking cessation), it is likely that clinical psychologists would spend more time on smoking cessation
counseling. Such an increased investment of time in
J Community Health (2009) 34:461–471
cessation counseling would likely result in increased quit
rates among mental health patients.
The most frequently cited perceived barriers to providing smoking cessation counseling were ‘‘not the patients
presenting problem,’’ ‘‘I do not see this as a priority for my
client,’’ and ‘‘may interfere with therapy goals.’’ These
findings indicate that clinical psychologists are concerned
that smoking cessation counseling may interfere or be
detrimental to the treatment of the primary mental health
issue of the client. This finding is corroborated by similar
findings from other studies [15, 19]. Yet, research indicates
that a concurrent treatment approach to both the presenting
mental health issue and tobacco use is feasible [44]. Past
research also demonstrates that psychologists’ concerns
that smoking cessation counseling may interfere with
treatment for mental health are not valid. Smoking initiation has been shown to precipitate mental disorders like
stress, panic/anxiety disorders and depression [13, 45, 46].
Furthermore, smoking cessation has been shown to alleviate anxiety and depressive symptoms [47]. In addition,
smoking cessation treatment for substance abusers does not
have any adverse effect on drug use treatment outcomes
[48]. Moreover, substance abusers who smoke are more
likely to die from tobacco related diseases than from substance use related causes of death [49].
The majority of clinical psychologists in this study were
confident (high efficacy expectations) in their ability to
effectively apply the USPHS’s 5A’s method of cessation
counseling. Nonetheless, clinical psychologists who were
current smokers or ex-smokers were significantly less
confident in their ability to apply the 5A’s (low efficacy
expectations) as compared to clinical psychologists who
had never smoked. This demonstrates that clinical psychologists’ smoking status does significantly influence their
perceptions and approach to counseling patients who
smoke. In a recent Swedish study, psychologists that were
smokers were less likely than non-smokers to discuss
tobacco use with their patients. However, this 9% difference was not statistically significant [20].
Nicotine replacement therapy (NRT) has been shown to
significantly increase quit rates among smokers [17, 30, 38,
50, 51]. Nonetheless, the majority of clinical psychologists
in this study did not always recommend NRT for their
patients who smoke. Similarly low rates of prescription or
recommendation of NRT has been reported among other
health care providers [52].
Limitations
This study had several potential limitations. First, because
the study was a cross-sectional study of clinical psychologists’ smoking cessation practices and perceptions, no
cause and effect relationship can be drawn from the results.
469
Second, the monothematic nature of the survey instrument
may have sensitized some respondents to the research issue
resulting in a response bias, which could potentially
threaten the internal validity. Third, since the study was
delimited to doctoral level clinical psychologists who are
registered in the 2005 directory of the National Register of
Health Service Providers in Psychology, the results of the
study may not be generalizable to all clinical psychologists
in the United States. Fourth, the responses obtained using
the survey instrument relied on self-reporting. It is therefore a subjective account of clinical psychologists’ smoking cessation practices. No attempt was made to validate
these self-reported practices. To the extent there were
inaccuracies in the self-reported practices, this too could be
a threat to the internal validity of these findings.
Conclusion
This is the first randomized study of American psychologists’ perceptions and practices regarding smoking cessation with a return rate of more than 50%. Results indicate
that there is much room for improvement as we strive to
close the gap between the current rates of delivery of the
5R’s and the 5A’s and the ideal rates of delivery. Leaders
in the fields of medical education and clinical psychology
can play a major role in closing this gap.
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