Psychological Services 2014, Vol. 11, No. 3, 317–323

In the public domain DOI: 10.1037/a0036610

To Treat or Not to Treat: Should Psychologists Treat Tobacco Use Disorder? Linda P. Bodie Cincinnati VA Medical Center, Cincinnati, Ohio, University of Cincinnati College of Medicine The author presented this Presidential Address for Divison18, Psychologists in Public Service, at the 2012 American Psychological Association Convention in Orlando, Florida. The address challenges public service psychologists to reduce the tobacco disease burden through their roles as researchers, leaders, educators, and practitioners and explains why treating tobacco use disorder is important and relevant for psychologists. The address discusses the prevalence and the resulting mortality and morbidity rates of tobacco use disorder, which call for effective evidence-based interventions that can be integrated by psychologists into other ongoing treatments. Treatment of the underserved populations, including those with serious mental illness and/or substance use disorders, presents many barriers. In addition, education and training for tobacco use disorder in undergraduate and graduate clinical psychology programs present further barriers for psychology trainees. However, progress is being made because of the numerous resources and psychology leaders who are advocates for tobacco use disorder treatment and research. Challenges for the future include increasing awareness of the importance of treatment for tobacco use disorder, finding innovative ways to increase access to comprehensive evidence-based treatment, and acknowledging that psychologists can make a difference in reducing the tobacco use disorder disease burden. Psychologists have an ethical and professional responsibility to treat tobacco use disorder. Keywords: nicotine dependence, tobacco dependence, tobacco use disorder, smoking cessation, nicotine addiction

The scenario changes—the patient revealed that she is expecting her third child. The psychologist thought, “It is very dangerous for her to be smoking while pregnant; neither should she be smoking around her other small children. This adds to my dilemma about talking to her about her tobacco use. What should I do?” To treat or not to treat? Another scenario—a different patient has schizophrenia. He claims that smoking diminishes his auditory hallucinations. He also suffers from several serious medical problems, including emphysema, diabetes, and hypertension. The patient sees a psychiatrist and is on several psychotropic medications. The psychologist thought, “I won’t say anything; after all, maybe his psychiatrist will ask about his tobacco use. On the other hand, what if his psychiatrist does not address his smoking and he gets sicker and dies—would I be responsible?” Psychologists address other problematic and dangerous behaviors that may not be the presenting problem, so why not treat tobacco use disorder? To treat or not to treat? One of the Presidential Initiatives for Division 18 was to increase the awareness of the importance for psychologists to be involved in the treatment of tobacco use disorder through their many different roles as researchers, leaders, educators, and practitioners. Psychologists in community mental health facilities, corrections, state and community hospitals, Indian country, universities, research settings, and the Veterans Administration (VA) are uniquely prepared through their training and education to make a difference in reducing tobacco disease burden, whether it be through clinical work, consultation, education and training, program evaluation, or research. Psychologists in the public sector

In the January/February 2008 issue of The National Psychologist, Dr. Garland Y. DeNelsky wrote, “As the session ended, the psychologist and the patient rose simultaneously and started moving toward the door. With one smooth motion, the patient reached into her purse, retrieved a package of cigarettes and took one out. She said her goodbyes and hurriedly walked away, apparently eager to exit the building and light her cigarette. The psychologist thought, should I bring up her smoking and the need for her to quit at our next session? Would that prove too stressful for her? Does she actually need her smoking as a means of helping her cope? And, of course, I must remember that she came to me for help with her emotional problems, not her smoking. What should I do?” (DeNelsky, 2008, p. 15). To treat or not to treat?

This article was published Online First May 26, 2014. Linda P. Bodie, Cincinnati VA Medical Center, Cincinnati, Ohio; Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine. This paper was adapted from the APA Division 18 Presidential Address presented at the 2012 Annual APA Convention in Orlando, Florida. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the Department of Veterans Affairs. The author thanks Susan Myre for her assistance in preparing this article, Lynn Goodwin for her expertise in proofreading, and Dr. Kim HamlettBerry for her editorial comments. Correspondence concerning this article should be addressed to Linda P. Bodie, Cincinnati VA Medical Center 116B, 3200 Vine Street, Cincinnati, OH 45220. E-mail: [email protected] 317

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have many challenges in doing this, including time constraints, lack of training in treating tobacco use disorder, reimbursement issues, and the belief that treating tobacco use disorder is not within the psychologist’s professional responsibilities (Jaén, Stange, & Nutting, 1994; Ziedonis, Guydish, Williams, Steinberg, & Foulds, 2006). This paper will focus on the mortality and morbidity related to tobacco use disorder, the prevalence of tobacco use disorder, the relevance for psychologists to treat tobacco use disorder, and treating the underserved populations, including the seriously mentally ill, the substance use disorder population, and those with posttraumatic stress disorder (PTSD). Education and training issues as well as challenges for the future will also be discussed.

Mortality and Morbidity Tobacco use is the leading cause of preventable disease and death in the United States. Tobacco use results in 443,000 premature deaths annually in the United States (Centers for Disease Control and Prevention, [CDC], 2008). An estimated 25 million Americans alive today will likely die from a tobacco-related illness (CDC, 2011). Another 8.6 million live daily with serious illnesses caused by tobacco use (Mumford, 2009). There is a significant risk of spending the last 10 –15 years of life disabled by tobacco disease burden (Doll, Peto, Boreham, & Sutherland, 2004). Each year tobacco kills twice as many Americans as alcohol, cocaine, heroin, homicide, suicide, car accidents, fires, and AIDS combined (Baca & Yahne, 2009; CDC, 2008).

Prevalence of Tobacco Use Disorder The percentage of the general adult population in the United States who use tobacco has dropped dramatically from 40% to 19.3% in 2010. However, the decline in adult tobacco use rates has stalled; even with all of the information about the harmful effects, approximately 45.3 million adults continue to smoke (CDC, 2011). Tobacco use is a health disparity issue, with higher prevalence rates among those with comorbid psychiatric and/or substance use disorders, those with lower income, and the unemployed. “High school dropouts are three times as likely to smoke as those with college degrees” (Volkow, 2012, p. 2). Populations such as Native Americans reported a 32% prevalence rate of tobacco use (Volkow, 2012). Of particular concern are the rates and intensity with which pregnant women smoke, especially those who have dropped out of high school, thereby incurring health risks for their unborn children and themselves. About one in six pregnant women, aged 15– 44, smoke cigarettes (Volkow, 2012). In the Veterans Health Administration (VHA), it was reported that 14.5– 24.7% of 2011 new VA enrollees are tobacco users (Department of Veterans Affairs, Office of ADUSH for Policy & Planning, 2011). Not only is the cost of tobacco use in human suffering and premature death a tremendous problem, but the economic cost is also staggering. The total economic burden is nearly $193 billion annually, including $96 billion in medical expenditures and another $97 billion in lost productivity (CDC, 2011; Mumford, 2009). In 2009, an Institute of Medicine report estimated that tobacco-related disease represented the single most expensive health problem in the VHA, with $9 billion of $40 billion in the 2008 VHA budget spent to treat tobacco-related illness (Institute

of Medicine, Committee on Smoking Cessation in Military and Veteran Populations, 2009).

Is Tobacco Use Disorder Treatment Relevant for Psychologists? An article in the American Psychologist reviewed the Agency for Health Care Policy and Research, “Smoking Cessation Clinical Practice Guidelines,” and it delineated recommendations with respect to implications for the field of psychology. It was concluded that treating tobacco use disorder, frequently comorbid with other mental health and substance use disorders, is indeed quite relevant for psychologists (Wetter et al., 1998). First, nicotine dependence was recognized and listed as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders (fourth edition; DSM–IV) and currently in DSM-5 as a tobacco use disorder (American Psychiatric Association, 2000, 2013). The DSM-5 Substance-Related Disorders Work Group recommended revisions for DSM-5, including changing the name from “nicotine dependence” in DSM–IV–TR to “tobacco use disorder” and aligning tobacco use disorder with criteria for the other substance use disorders (Hasin et al., 2013). “Nicotine dependence can develop with use of all forms of tobacco (cigarettes, chewing tobacco, snuff, pipes, and cigars)” (American Psychiatric Association, 2000, p. 264). “Cessation of tobacco use can produce a well-defined withdrawal syndrome” (American Psychiatric Association, 2013, p. 572) and can produce significant emotional distress. Nicotine is the most addictive, prevalent, and treatable drug of dependency. Nicotine is so highly addictive because it is rapidly absorbed, reaching the mesolimbic reward area of the brain within 10 –20 seconds, where it activates the dopamine system, similar to cocaine and natural rewards. Nicotine mediates psychoactive properties; that is, it elevates mood, decreases anxiety and appetite, increases arousal, and enhances cognitive functioning (Prochaska, 2010a; Stall, 2000). However, of the approximate 7,000 toxic chemicals in tobacco smoke (U.S. Department of Health & Human Services, 2010), nicotine is relatively innocuous (Prochaska, 2010a). It is the tobacco smoke, not the nicotine, which is deadly. Psychologists have expertise in understanding and treating other addictions, so why not also treat this deadly addiction? Second, tobacco use disorder manifests as a behavior that psychologists are well equipped to manage. In fact, the development and dissemination of assessment and intervention techniques for tobacco use was actually led by psychologists (Lando, McGovern, & Sipfle, 1989; Prochaska, DiClemente, & Norcross, 1992). Dr. Kenneth Weiss, from the Cleveland VA, provided tobacco use disorder treatment for 25 years. Dr. Weiss (personal communication, date unknown) once said, “Many people think you just need a manual, but it takes more than that. It takes someone who knows behavioral change. Psychologists know behavioral change.” Aren’t psychologists in the business of helping people change their behavior to live more satisfying, functional lives? Third, tobacco use is a health issue. At the March, 2011 American Psychological Association (APA) State Leadership Conference in Washington, DC, it was noted that rapid changes in health-care services mean that an increasing share of services will be moving into the public sector. Psychologists have the expertise and training that make them well suited for leadership and supervisory positions. However, psychologists must ag-

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gressively assume leadership roles in this evolving health-care system, including health promotion and disease prevention. Prevention is vital because first-time tobacco users have a 68% chance of sooner or later becoming dependent on nicotine (Lopez-Quintero et al., 2011). Dr. Katherine C. Nordal, Executive Director of APA Practice Directorate, stated at the 2011 Leadership Conference, “Psychologists must take an active role as regulations are developed to implement reforms . . . if we aren’t at that table . . . it will mean we are on the menu” (Nordal, 2011). We must not shy away from administrative roles in which we have the opportunity to develop and implement policies for our facilities or hospitals. As leaders and policymakers, psychologists can have a positive effect on the health of their patients and employees by designing, implementing, and evaluating tobacco treatment efforts through consultative services, program evaluation, and performance improvement initiatives (Wetter et al., 1998). Norman B. Anderson, APA Chief Executive Officer, stated in the February 2011 issue of the Monitor on Psychology that as we work toward the “patient-centered medical home, physicians, nurses, and physicians’ assistants need our help to address the behavioral factors tied to chronic health problems, such as smoking, obesity, sedentary lifestyles, and lack of compliance to treatment regimens” (Anderson, 2011, p. 9). As we move forward into the 21st century, it is vital that psychologists encourage, advocate, and promote integration of physical and mental health care. The notion that the mental state cannot be separated from the physical state is finally catching on. Psychologists have exciting opportunities to integrate services into primary care, serving as consultants to physicians and other health-care providers. Do psychologists want to leave this in the hands of other clinicians who may have little knowledge and training in behavioral interventions, skill development, or cognitive behavior therapy? This is not implying or suggesting that other clinicians cannot treat tobacco use disorder. However, where are the psychologists? Despite all of the reasons psychologists should be involved, there is little evidence that psychologists view tobacco treatment as a fundamental professional obligation (Wetter et al., 1998).

Treating the Underserved Populations Dr. Nora D. Volkow, Director of the National Institute of Drug Abuse (NIDA), reported “a large portion of today’s smokers belong to underserved populations that have not benefited as much as the general population from health information and clinical advances. The challenge is to extend the progress that has been made to the hardest-to reach individual and groups and those with the most severe smoking addictions” (Volkow, 2012, p. 2). A survey of the prevalence of tobacco use by psychiatric diagnosis shows that individuals with psychiatric and substance use disorders are twice as likely to use tobacco than those without these illnesses (Lasser et al., 2000; Prochaska et al., 2013). Tobacco use prevalence ranges from “about 50% to 90% among individuals with schizophrenia, bipolar disorder, depression, and substance use disorders” (Volkow, 2012, p. 2). Although people with psychiatric disorders only make up 7% of the population, they smoke 44% of all cigarettes in the United States (Lasser et al., 2000). Individuals with psychiatric disorders tend to smoke more hightar cigarettes, smoke more cigarettes per day for longer periods of

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time, inhale more deeply, and extract more nicotine per cigarette. These behaviors result in more severe levels of tobacco use disorder (Gottlieb & Evins, 2007). Approximately one third of their income is spent on cigarettes (McDonald, 2000). Many consider cigarettes more desirable than food or shelter. Tragically, individuals with psychiatric disorders are likely to die 25 years prematurely of medical disorders caused by tobacco use (Baca & Yahne, 2009; CDC, 2006; Colton & Manderscheid, 2006; Prochaska et al., 2013). A study with veterans diagnosed with psychiatric and substance abuse disorders found that “Veterans with psychiatric disorders are motivated to quit smoking and should be offered cessation services” (Duffy, Essenmacher, Karvonen-Gutierrez, & Ewing, 2010, p. 105). In addition, tobacco disease burden is the leading cause of death in patients with other substance use disorders. An early study reported that one half of these substance abuse patients died from a tobacco-related illness rather than from their presenting drug of choice (Hurt et al., 1996). Although morbidity and mortality are typically cited as the most significant consequences of tobacco use, there are other negative consequences among individuals with psychiatric disorders that are often overlooked. For example, the tars in tobacco smoke induce production of liver enzymes that hasten the metabolism of some mood-stabilizing psychiatric medications, resulting in the need for increased dosages, higher costs, and more side effects (Bigos et al., 2008). Although persons with schizophrenia are afflicted with higher rates of tobacco disease burden, they are less likely to receive treatment for tobacco use disorder (Goff et al., 2005). The same is true for those with other addictive disorders. Results of the (SAMHSA; Substance Abuse and Mental Health Services Administration, 2010) report showed that only 24.5% of facilities providing substance use disorder services also offered tobacco treatment programs. Only 19.7% of facilities provided nicotine replacement therapies, whereas only 15.2% provided non-nicotine medications such as bupropion and varenicline. The end result: “Until drug treatment facilities systematically treat their patients’ tobacco use, millions will flow through treatment systems, overcome their presenting drug of abuse, but die prematurely from tobacco-related illnesses” (Richter & Arnsten, 2006, p. 1). There are many barriers associated with treating tobacco use in the mentally ill and substance use disorder patients. There is a widespread misconception that patients with psychiatric or other substance use issues do not want tobacco treatment. In actuality, research has shown that patients with mental health and substance use disorders do also want to address their tobacco use (Baca & Yahne, 2009; Duffy et al., 2010; Friedman, Jiang & Richter, 2008; Ziedonis et al., 2006). There is the belief that these patients will either be unable to initiate abstinence or have too much difficulty maintaining it. Clinicians may believe that their patients need tobacco to help them cope with stress or that abstinence will result in increased anxiety and outbursts in psychiatric and substance use disorder units (Prochaska et al., 2013; Ziedonis et al., 2006). There are still treatment facilities that use tobacco as a “reward” for good behavior or, conversely, as a punishment by denying “smoke breaks” for noncompliant behavior. Therefore, tobacco use is reinforced as a coping strategy and used to stabilize mood. The signs of nicotine withdrawal may be interpreted as an exacerbation of the symptoms of mental illness, so clinicians give out tobacco to “calm the patient down.” However, the immediate

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effects of nicotine are not calming. Instead, nicotine causes a temporary rise in blood pressure and heart rate (U.S. Department of Health & Human Services, 2010). Tobacco should not be used to manage stress because it is not an effective coping strategy (Prochaska, 2010a). Patients often cite “stress” as a primary reason for smoking and confuse the relief of their nicotine withdrawal as relieving their stress. It is likely that the stress tobacco users report is actually due to the effects of nicotine withdrawal as nicotine levels decrease between uses (Prochaska, 2010b). In fact, research has shown that those who remain abstinent from tobacco use for a substantial period of time report a reduction in overall stress levels (Parrott, 1999). In addition, individuals with mental illness and other substance use disorders may be reluctant to seek tobacco treatment for fear of failure. They may be misinformed about the risks/benefits of using U.S. Food and Drug Administration-approved treatment medications such as nicotine replacement therapy, bupropion, or varenicline. Some may be suspicious of using a nicotine replacement product, believing it can cause cancer or a heart attack, especially if they concurrently use nicotine replacement products and tobacco (Gottlieb & Evins, 2007). These patients are likely to use tobacco for socialization purposes, with most of their social contacts also being heavy tobacco users (Gottlieb & Evins, 2007). In these circumstances, they will receive little encouragement to seek treatment. Individuals with schizophrenia may experience improvement in some aspects of cognitive dysfunction from the nicotine in tobacco, thereby decreasing the motivation for abstinence. In addition, the cognitive impairment of mental illness can hamper one’s ability to follow through with treatment recommendations for tobacco use disorder (Gottlieb & Evins, 2007). Tobacco use disorder has traditionally been minimized, neglected, or ignored in the treatment for other substance use disorders. Clinicians may worry that discussion about tobacco use disorder will interfere with the therapeutic relationship. Slogans from 12-step fellowships such as “no major changes until one year of sobriety,” “first things first,” and “one step at a time” imply that quitting smoking should not be the first priority. It is notable that Bill W., one of the founders of Alcoholics Anonymous, was a chain smoker who was able to become abstinent from alcohol but died from emphysema caused by smoking until his death (Cheever, 2004). Many false beliefs that remain regarding providing tobacco treatment in substance abuse programs are based on myths and “old school” thinking, which are a result of fears of the clinician or staff, not the patient. The belief that it is too hard to maintain abstinence from all addictive drugs at once or that tobacco abstinence may negatively affect recovery from other drugs is widely held. However, there is no evidence that tobacco abstinence interferes with other sobriety (Baca & Yahne, 2009; Prochaska, 2010a; Ziedonis, Guydish, Williams, Steinberg, & Foulds, 2006). There is a large body of research with excellent results supporting a combination of behavioral and pharmacological interventions (Baca & Yahne, 2009; Prochaska, 2010a). Indeed, abstinence from tobacco actually increases other drug abstinence by 25% (Baca & Yahne, 2009; Foulds et al., 2006; Hurt et al., 1996). A study at the Cincinnati VA Medical Center examined outcomes of a voluntary smoking cessation treatment program during a residential substance abuse program and demonstrated that motivated smokers could initiate smoking abstinence with pharmacotherapy and be-

havioral counseling (Heffner et al., 2007). Another study suggested that even educational strategies to increase motivation to stop smoking were beneficial in residential substance abuse treatment (Stack, Goalder, Calhoun, Bradshaw, & Samples, 2009). Regardless, even modest abstinence rates result in clinically significant gains in health (Heffner et al., 2007). Tobacco users with a major mental illness and/or other substance use disorder can be treated effectively with evidence-based interventions. A clinical demonstration project by Dedert et al. (2010) suggested that a brief, low-cost intervention was feasible and promoted tobacco abstinence in veterans with PTSD. Dr. Miles McFall has conducted extensive research concerning the integration of tobacco treatment into the care of patients with PTSD. His findings suggest that tobacco treatment interventions can be safely and effectively incorporated into mental health care for PTSD (McFall et al., 2006, 2010, 2005). McFall et al. (2010), who completed the first multisite, randomized controlled study and the largest published clinical trial of treating smokers with mental illness, concluded that integrating smoking cessation treatment into mental health care resulted in greater prolonged abstinence when compared with referral to specialized cessation treatment (Prochaska, 2010). Psychologists must be aware of the importance of including treatment for tobacco use disorder in all settings, including acute inpatient medical and psychiatric units, PTSD programs, and substance use disorder programs.

Education and Training Issues Health-care programs should place a greater emphasis on tobacco treatment. Training in the treatment of tobacco use disorder should be a part of the undergraduate and graduate school curriculum (Akpanudo, 2006; Morrell, Cohen, & Dempsey, 2008). However, undergraduate and graduate clinical psychology programs generally have no courses or little training in relation to tobacco use disorder. Kleinfelder (2010) explored the tobacco use disorder curricula and training in graduate clinical psychology programs. The results demonstrated that 91.1% of the 110 clinical psychology programs surveyed offered no formal tobacco treatment education in their curricula. Only a small percentage of clinical psychology directors (12.7%) indicated their programs offered more than 3 hours of education. Furthermore, 45.5% of the clinical psychology directors indicated that tobacco treatment education was not an important part of the curriculum. Those directors without formal training themselves (70.9%) thought this education was not at all important. When tobacco treatment training was offered, it was an elective rather than a requirement. These results suggest that clinical psychology students do not receive consistent, standardized education or experiential training in the treatment of tobacco use disorder. The barriers to standardized nicotine dependence education, as identified by clinical psychology directors, include a perception of lack of time in the curriculum, low priority, lack of requirements from accreditation bodies, and lack of student interest in tobacco training (Kleinfelder, 2010). The psychology directors suggested that students could get training about tobacco use disorder on their own if they are interested. Of course, a student can pursue training about any subject on his or her own. However, students would need to be aware of trainings and certifications regarding evidence-based tobacco treatment in the first place. In addition,

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students would need information about the importance of such training and encouragement to seek the training. Students are the future of psychology. If substantial changes are not made in the curricula of these programs, then how will our students receive education and training in the treatment of tobacco use disorder? Practicum students, psychology interns, and postdoctoral fellows can be especially helpful in the development of programming and the implementation of treatment. Dr. Timothy Carmody, Chair, VA Section, Division 18 and Chair, VHA Technical Advisory Group (TAG), Clinical Public Health Group, chaired a subcommittee of the TAG to develop a curriculum for VHA internship directors to assist psychology interns to facilitate tobacco treatment for those in VHA predoctoral internship or postdoctoral fellowship programs. Indeed, with the current state of education, students and practicing psychologists may need to seek out specialized training to catch up to those who are already able to treat tobacco use disorder. Several agencies throughout the country provide training and certification for the designation as a Certified Tobacco Treatment Specialist (CTTS) or Nicotine Dependence Specialist (NDS). These agencies require certain qualifications to be met, completion of an intensive training course, documentation of clinical hours in the treatment of tobacco use disorder, passing of knowledge and skills-based tests, and the completion of required tobacco-related continuing education hours for renewal. The Mayo Clinic offers the longest-standing CTTS certification program. In 2011, there were 33 participants from around the world who attended one of the Mayo Clinic’s 5-day trainings on tobacco cessation treatment. The attendees included respiratory therapists, nurses, pulmonologists, social workers, peer support specialists, counselors, and only one psychologist (the author). Where were the psychologists? However, there is good news. The growing area of health psychology promotes healthy lifestyles by making positive behavioral changes. Health psychologists make substantial contributions to the treatment of tobacco use disorder. In addition, the U.S. Department of Veterans Affairs established a national program office as part of the Clinical Public Health Group, which is responsible for tobacco policy and programs. Dr. Kim Hamlett-Berry, a clinical psychologist and Program Director of the Tobacco and Health: Policy and Programs led the initiative to establish two field-based Tobacco Cessation Clinical Resource Centers (TCCRCs) within VHA. The Cincinnati and San Diego VA Medical Centers were awarded funding to develop these resource centers to enhance the VHA’s public health response to tobacco use disorder among veteran populations. The goals of the Cincinnati TCCRC specifically are to advance the dissemination and implementation of evidence-based tobacco treatment programs throughout facilities in the U.S. Department of Veterans Affairs, assist VA Medical Centers to overcome barriers to tobacco treatment, address staff concerns, dispel myths, develop curricula for clinicians, provide resources, mentor clinicians to solidify new skill acquisition, and revise organizational policies and practices, as they are identified, that may impede progress. To date, the outcomes of the TCCRC efforts have been very promising. Comparison of the pre- and postsurveys have found improved attitudes toward tobacco treatment, increased knowledge and skills, identification of designated champions, development of an open cohort,

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ongoing evidence-based treatment, and increased access to medications. The VA is also quite supportive of psychologists in leadership roles in treatment, research, and advocacy. For example, the VA Office of Research and Development supports Dr. Alex Sox-Harris as the Director, with Dr. Elizabeth Gifford as the Clinical Coordinator, of the Substance Use Disorder Quality Enhancement Research Institute (SUD-QUERI). Through research and clinical applications, this program seeks to improve the detection and treatment of veterans with hazardous substance use to include tobacco. Dr. Daniel Kivlahan, National Mental Health Program Director, Addictive Disorders, is another psychologist influential in the field of substance use disorders and is a strong advocate for tobacco treatment in his various VA leadership roles. In addition, the U.S. Department of Veterans Affairs mandated that each VA Medical Center hire a health behavior coordinator whose duties include tobacco use disorder treatment. These are designated as “psychologist’ positions.” What wisdom and vision the VA Central Office demonstrated by designating these positions for psychologists.

Evidence-Based Treatment for Tobacco Use Disorder There are effective treatments that significantly increase the rate of long-term abstinence. These are outlined in Treating Tobacco Use and Dependence: Clinical Practice Guideline 2008 Update (Fiore et al., 2008). Evidence-based tobacco use disorder treatment saves lives, reduces disability, improves health and quality of life, increases sense of control, and helps patients lead more functional lives. It reduces the risks of cardiovascular disease, cancer, low birth rate, respiratory illness, and sudden infant death syndrome in their children (Richter & Arnsten, 2006). It is cost-effective, relatively easy to provide, and decreases prevalence rates of tobacco use disorder. Tobacco use disorder morbidity and mortality rates call for interventions that can be fully integrated into other ongoing treatments without adverse effects (Baca & Yahne, 2009; McFall et al., 2006, 2010, 2005; Ziedonis et al., 2006). Evidence-based treatment for tobacco use disorder includes behavioral counseling and medication. Several of the effective medications (e.g., nicotine replacement patches, gum, and lozenges) are available over-the-counter. Therefore, psychologists can advise/suggest without having to write a prescription. Medicare covers counseling and pharmacotherapy (nicotine replacement therapy, bupropion) for those with tobacco-related health conditions (Prochaska, 2012). Many insurance companies also pay for treatment for tobacco use disorder. It is important to screen for tobacco use, include it on the patient’s treatment plan, provide motivational interventions, and discuss coping strategies. The success rates increase with more intensive counseling. However, brief counseling (e.g., 2–5 min) has been shown to be effective in helping people initiate abstinence from tobacco. However, a study of inpatient smokers in the VA showed that although 70% indicated they were motivated to quit, only 17% received some type of tobacco cessation services during their hospitalization (Duffy, Reeves, Hermann, Karvonen, & Smith, 2008). At the very least, if the psychologist cannot treat tobacco use, a referral should be made to someone who can. If the psychologist asks just two questions, it may make a difference. These two questions are “Do

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you use tobacco products of any kind?” and “Would you like to quit?” (Mumford, 2009, p. 23). The answers may be surprising. Most importantly, the psychologist will not have ignored the patient’s tobacco use disorder. Finally, Dr. John Hughes, a psychiatrist who has given many presentations and has published extensively on the topic of tobacco use disorder, stated in 1997 (as cited in Prochaska, May, 2012) “Those who deliver mental health care often pride themselves on treating the whole patient, on seeing the big picture, and on not being bound by financial irrationality or by the biases of their culture; yet many fail to treat nicotine dependence. They forget that when their patient dies of a smoking-related disease, their patient has died of a psychiatric illness they failed to treat.” When psychologists’ patients die of a tobacco-related illness, do they forget that they died of an illness they failed to treat? Isn’t it their ethical duty to treat tobacco use disorder? Challenges for the future include increasing awareness of the importance of treatment for tobacco use disorder, improving undergraduate and graduate training programs for tobacco use disorder, developing innovative ways to increase access to comprehensive evidence-based treatment, and acknowledging that psychologists can make a difference in tobacco use disorder with their patients in all settings.

Conclusion Thank you for your interest in the integration of tobacco treatment into psychologists’ practice, training programs, internships, practicum sites, facilities, hospitals, community mental health centers, universities, and criminal justice systems. I want to end with a quote from an e-mail that I received from Dr. Laura Bolte, a community mental health psychologist, who was a former psychology intern of mine, “It’s been 15 years or so since you were my supervisor. Your energy, outlook, and genuineness have been a great influence over the years. I still hear your voice when I launch into working with my clients about their tobacco use, even if just working to cultivate their motivation. It’s a friendly association that I tuck into my day” (personal communication, May 12, 2012). If only all psychologists would think in those terms and decide, if nothing else, to “work on cultivating their motivation” to address tobacco use. Are we, as psychologists, doing the right thing if we neglect, ignore, or minimize tobacco use disorder when it is the most deadly of all addictions? Prochaska (2010a, p. 177) states, “Providers in mental health and addiction treatment settings have an ethical duty to intervene on patients’ tobacco use and provide available evidencebased treatments.” Mumford (2009) stated that many psychologists already ask their clients about other unhealthy behaviors. He poses the question (Mumford, 2009, p. 21) “What if every psychologist with tobacco-using patients engaged his or her clients in a discussion about the health benefits of discontinuing tobacco use?”

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Received December 29, 2013 Revision received March 4, 2014 Accepted March 7, 2014 䡲