Tobacco: Recovery Across the Continuum

"Tobacco: Recovery Across the Continuum" (TRAC) is a stage-based motivational service model designed specifically to help people diagnosed with severe mental illness and/or substance use disorders to reduce and eventually eliminate the use of tobacco products. TRAC integrates tobacco treatment with existing behavioral healthcare approaches.

TRAC equips service providers with strategies to connect with people in all "stages of change," including those who are either unaware of or ambivalent about the benefits of reducing and eliminating tobacco use as well as those who are ready to reduce and become tobacco-free.

INTEGRATED APPROACH

TRAC utilizes the best available knowledge to address the biopsychosocial needs of people diagnosed with severe mental illness and/or substance use disorders. TRAC integrates core components of several interventions, practice guidelines, and established and emerging empirical research, including but not limited to the following:

• Integrated Dual Disorder Treatment (IDDT)
• Transtheoretical Model of Change (TTM) (a.k.a., stages of change)
• Motivational Interviewing (MI
• Cognitive Behavioral Therapy (CBT)
• Treating Tobacco Use and Dependence Clinical Practice Guidelines, U.S. Department of Health and Human Services
• Supported Employment (SE)
• Illness Management and Recovery (IMR)
• Empirical evidence related to pharmacological treatments

CORE PRINCIPLES

There are 10 core principles to the TRAC model that facilitate the organizational change and clinical change that support consumers during their tobacco-recovery journeys:

1. Organization-wide effort
2. Integrated approach
3. Ongoing assessment
4. Stage-based approach
5. Motivational interventions
6. Group and individual services
7. Strong interdisciplinary communications
8. Involving natural supports
9. Psychopharmacological interventions
10. Implementation (program) outcomes & intervention (consumer) outcomes

MAKING THE CASE

Tobacco Epidemic:

• Research shows that more than 75 percent of people diagnosed with a severe mental illness or substance use disorder consume tobacco products.
• In contrast, the rate of tobacco use in the general population has declined steadily to about 20 percent nationally.
• Over 44 percent of the cigarettes smoked in the United States are consumed by people with psychiatric disorders.

Health Consequences:

• People diagnosed with severe mental illness die, on average, 25 years earlier than their non-mentally ill peers. Many of these deaths are caused by tobacco-related illnesses, such as cancer, heart disease, and emphysema and other lung diseases.

• People diagnosed with schizophrenia spend an average of 27 percent of their income on tobacco products.

Treatment Consequences:

• Tobacco interferes with the metabolism of many medications.
• Therefore, tobacco users often require higher doses of medication to get the intended therapeutic effect. In addition, with higher doses, there is a potential for increased side effects.
• Research shows that simultaneous treatment for alcohol, tobacco & other drugs will likely increase abstinence by up to 25 percent.

Service Challenges & Needs

• Traditionally, behavioral healthcare providers have viewed tobacco treatment as the responsibility of primary healthcare.
• Many tobacco-cessation approaches are designed to help people who are ready to quit (i.e., in the action "stage of change"), often overlooking those ambivalent about making a change.
• The high rate of tobacco use among people with severe mental illness or substance use disorders indicates that traditional approaches to tobacco cessation have not been very effective for this population.
• Yet, two-thirds of these tobacco users say they would accept help with quitting if that help were made available—and designed to meet their needs.

FIDELITY & OUTCOMES

There are treatment characteristics (components) and organizational characteristics of the TRAC model that are called fidelity domains. These domains encourage service systems and organizations to develop holistic integrated program structures and treatments. These domains also provide a structure for a continuous quality-improvement process that addresses multiple outcomes.

TRAC facilitates systems change, organizational change, and clinical change when it is implemented with fidelity. Organizations which maintain fidelity to the original design of TRAC are most likely to achieve and sustain the best outcomes. TRAC has a fidelity measure  that helps organizations implement and sustain the model (see "Related Resources" below).

RESEARCH & DEVELOPMENT

TRAC was developed and is studied by a team of researchers, consultants, and trainers at the Center for Evidence-Based Practices (CEBP) at Case Western Reserve University in Cleveland, Ohio in collaboration with the following:

• Ohio Department of Mental Health (ODMH)
• Ohio Department of Alcohol and Drug Addiction Services (ODADAS)
• Ohio Department of Health (ODH)

The following also provided consultation for development of the TRAC model:

• Carlo C. DiClemente, PhD, professor of clinical psychology, University of Maryland—Baltimore County (UMBC), and co-creator of the Transtheoretical Model of Change (stages of change).
• Jill Williams, M.D., associate professor of psychology and director of the Division of Addiction Psychiatry, UMDNJ-Robert Wood Johnson Medical School.

SOURCES

• Debra R. Hrouda & Barbara L. Wieder (2008). Nicotine Dependence: The Forgotten Substance-Related Disorder. Journal of Dual Diagnosis, v4, n2, p208-216.

RELATED RESOURCES

• Sending Tobacco Use Up In Smoke (Poster)

• TRAC Getting-Started Guide

• More Resources & Tool